Client Consent and Release for Email
We are now able to offer the use of email for:
• Appointment reminders
• Sharing routine test results
• Sending you forms for tests (labs, x-ray, ultrasound etc.)
• Giving you educational and health promotion resources
• Centre Newsletters
• Client satisfaction surveys
• Verifying your contact information
• Asking for health card information
• Sending you our policies
Please read to the bottom of this page. If you would like to receive our emails, please update your address book to accept emails from firstname.lastname@example.org and don’t forget to check your junk/spam folder.
There are some limits on what and when we can email you, which we will explain here:
• Email communication is not a substitute for meeting with your health care provider. Although technology is changing, the best way to share information with your health care provider is in person.
• Please tell us which email address you wish us to use. You must to keep this up-to-date and tell us of any changes to your email address.
• Email should never be used in an emergency. If you have a health emergency, you should page your midwife, call 9-1-1 or go to the nearest hospital.
• Email should never be used for urgent problems (where you need a response from us by a certain time). If you have an urgent issue, you should page your midwife or make an appointment to see your midwife by calling the office.
• We do not read our email messages 24 hours per day 7 days per week. We cannot guarantee any particular response time for an email. If you require a response, please call the office.
• Emails should be short. If you have a problem that is complex – please call the office instead.
You should not use email to tell us about sensitive health information.
There are some privacy risks in communicating by email:
• Email may not be secure. While we try to protect our emails we cannot guarantee the security and confidentiality of any email you send to or receive from us. As the message leaves the Midwifery Practice Group it is sent across the internet and it could be intercepted and read.
• More than just your midwife may need to read your email. Administrative staff supporting your health care provider and people providing coverage for your health care provider (like a locum midwife) may also read any email you send.
• Emails may be filed on your health record depending on the content of the email message and can become a permanent part of your health record. As part of your record, emails may be shared within our team or third parties, with your consent or if we are permitted or required by law (including with other health care providers and insurance companies).
• Email is easy to forge, easy to forward (sometimes accidentally and to many people) and may exist forever.
• We recommend you give us a personal email address that only you read. We recommend that you use an email address and system that is password protected. If you give us a family email address or share your email address with anyone else, you should know that other people may also receive or read emails we send to you. If you use a work email address, your employer may have a right to archive and look at emails sent from their systems. We recommend you avoid using a work email address.
• Midwives of Mississauga is not responsible for information loss due to technical failures.
• Midwives of Mississauga may choose not to deal with you by email if you are not able to follow our email rules.
I have read and fully understand this consent and release form. I understand the risks associated with using email with the Midwifery Practice Group and I accept those risks. I understand the limits set out for using email and I agree to follow those limits. I understand if I no longer wish to communicate with Midwives of Mississauga by email, I will tell my health care provider or the front desk staff person. I agree that Midwives of Mississauga (which for this agreement and release includes the Midwifery Practice Group and any affiliated midwife and their respective staff, agents and officers) shall not be responsible for any personal injury including death, or privacy breach (outside the control of the Midwifery Practice Group) or other damages as a result of my choice to communicate with the Midwifery Practice Group by email and I release and hold harmless Midwives of Mississauga from any liability relating to communicating with me by email.
If I had any questions about this form, I asked those questions and agree that my questions have been answered.
I understand I have the right to have legal advice about signing this form and what it means to me and have either sought that advice or have chosen not to seek such advice
Printable Version : EMAIL CONSENT FORM.