BCFH - Permission to Obtain Services VIA Telehealth, Skype™/Microsoft Teams/Facetime/Wikispace/Vimeo

Permission to Obtain Services via Telehealth, Skype™, Microsoft Teams, Facetime, Hangouts, Wikispace, or Vimeo
This information is entirely confidential

To best serve your child and family, it may be useful to receive services via Teheleath, Skype™, Microsoft Teams, Facetime, Hangouts, Wikispace, or Vimeo.

"Telehealth" refers to specialized communication services equipment that are commonly available at many hospitals and health clinics across British Columbia, allowing for secure and high-quality voice and video communication between families visiting such locations and the BC Family Hearing Resource Centre.

The other programs are all free internet software applications that allow users to transmit video streaming over the internet, via webcam, and/or to share various kinds of files. It may be necessary to share this information with other individuals or agencies who are involved with your child. Information to be shared is limited to what is necessary to enable us to work effectively with you and your child.
Information
Name of child *

First Name Last Name
Child's Date of Birth *

Month Day Year
Date
Does your family receive support/funding from the BC Early Hearing Program?

Yes No
In order to quickly provide information to you or other professionals providing service to your child, we sometimes use web camera services over the internet. We take precautions in using web cameras in an attempt to protect your privacy. However, since Skype™/Microsoft Teams/Facetime/Hangouts/Wikispace/Vimeo are public service, you need to be aware that sending information over the internet does include the risk of personal information being accidentally disclosed to other people (e.g. on the web). For this reason, we need your permission to utilize our services via Skype™/Microsoft Teams/Facetime/Hangouts/Wikispace/Vimeo. Telehealth services are more specialized and secure, but will also be included in this list.
Do you authorize us to provide services to your family through Telehealth/Skype™/Microsoft Teams/Facetime/Hangouts/Wikispace/Vimeo? *

Yes, I give my permission to receive services with BCFH through Telehealth/Skype™/Microsoft Teams/Facetime/Hangouts/Wikispace/Vimeo. No, I do not give permission to receive services with BCFH through Telehealth/Skype™/Microsoft Teams/Facetime/Hangouts/Wikispace/Vimeo.
Which of these services/options do you prefer to use? Please be advised that Telehealth, Skype, Microsoft Teams and Facetime are more secure options compared to the others, and as such, are preferable for the services we provide. *

Telehealth Skype Microsoft Teams Apple Facetime Google Hangouts Wikispace Vimeo
Name of parent/legal guardian filling out this form:

First Name Last Name
Today's Date

Month Day Year
Date
Signature *

Clear
Signature *
Should be Empty:

Permission to Obtain Services via Telehealth, Skype™, Microsoft Teams, Facetime, Hangouts, Wikispace, or Vimeo

Information