CONSENT TO USE ELECTRONIC COMMUNICATIONS

CONSENT TO USE ELECTRONIC COMMUNICATIONS
PHYSICIAN INFORMATION:
Primary Care Provider:
Address: 16-1594 Fairfield Rd, Victoria BC. Canada V8S 1G1

Phone: 7786772345
The physician has offered to communicate using the following means of electronic communication

Videoconference or TeleconferenceE-mail Communication (photos)
PATIENT ACKNOWLEDGEMENT AND AGREEMENT:
I hereby acknowledge and agree to engage in electronic communication with my health care provider.

I am comfortable to assume the risk of this communication. Assurance is offered from my care provider's office that every effort possible will be made to ensure both confidentiality and clinical accuracy.

I understand also that this consent can be withdrawn at any time.
Patient Date of Birth

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Patient Name
Patient Address
Patient Phone
Patient Email
example@example.com
Date

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Patient Signature

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