I confirm that the information provided above is true and correct, and that the Personal Health Number listed is current and valid.

By providing my home or mobile phone number, email address, and other personal information, I authorize Maywood Medical to use this information to contact me regarding appointment times, referral updates, test results, appointment reminders, and other limited healthcare-related information. I acknowledge that it is my responsibility to keep my contact information up to date.

I acknowledge that I am responsible for the payment of any services or treatments not covered by my provincial health plan or private insurance, including but not limited to: insurance forms, driver’s physicals, sick notes, employment and sports physicals, and the transfer of medical records.

I understand that any medical or healthcare treatment I receive from Maywood Medical or its physicians will be provided within the province of British Columbia. I agree that the courts of British Columbia shall have exclusive jurisdiction over any complaint, claim, or legal matter arising from or connected to my care and treatment, or any aspect of the physician-patient relationship.

I further agree that any disputes arising from or in connection with this relationship shall be governed by, and interpreted in accordance with, the laws of the province of British Columbia (excluding conflict of law rules) and the applicable laws of Canada.

I authorize Maywood Medical to access my health information stored elsewhere—including my PharmaNet medication profile—for the purpose of providing appropriate care and treatment. This consent remains valid unless revoked by me in writing.

Risks of using electronic communication

The clinic and your physician will take reasonable steps to protect the privacy and confidentiality of electronic communications. However, due to the nature of electronic communication, certain risks cannot be entirely eliminated, including:

• Increased risk of disclosure to third parties when sensitive information is shared electronically.

• Despite best efforts, full security of electronic communications cannot be guaranteed.

• Employers and online service providers may have the legal right to access and retain communications transmitted through their systems.

• Electronic communications may contain malware that can damage or disrupt devices, networks, or security settings.

• Messages may be forwarded, intercepted, stored, or altered without the knowledge or consent of the sender or recipient.

• Backups may retain deleted communications even after both parties have removed them.

• Communications may be disclosed under legal obligations such as court orders or reporting duties.

• Consumer-grade videoconferencing platforms (e.g., Skype, FaceTime) may pose higher risks of interception.

• Messages can be misdirected, increasing the risk of being received by unintended recipients.

• Email, texts, and instant messages are easier to falsify than traditional hard copy communication, and verifying the sender’s identity is not always possible.

Conditions for Using Electronic Communication ("the Services")

• The physician will attempt to review and respond to electronic communications in a timely manner but cannot guarantee response times. The Services must not be used for urgent or emergency situations.

• If a response is required and has not been received within a reasonable period, it is the patient’s responsibility to follow up.

• Electronic communication is not a replacement for in-person visits, telephone communication, physical examinations, or emergency care when necessary.

• Messages relating to diagnosis or treatment may be transcribed into your medical record. Authorized staff, including administrative and billing personnel, may access these records.

• The physician may share messages with relevant staff and care providers involved in your treatment but will not share them with third parties (including family members) without your written consent, unless required by law.

• Patients and physicians agree not to use electronic communications for sharing highly sensitive medical information.

• You may request that specific types of information not be shared via electronic means by informing your physician in writing.

• The physician is not responsible for communication failures due to technical issues with your software, devices, or internet provider.

Instructions for Communication Using the Services

To ensure safe and appropriate use of electronic communication, patients must:

• Avoid using employer-owned or shared computers for personal medical communication where possible.

• Promptly inform the clinic of any changes to your email address, mobile number, or other contact details used for communication.

• Carefully review messages before sending to ensure clarity and completeness of information.

• Protect your privacy by using screen locks, secure passwords, and safe browsing practices.

• Withdraw consent for electronic communication only via phone, email, or written notice to the clinic.

• If you require immediate medical attention or if your condition worsens, do not rely on electronic communication. Contact the clinic directly or go to the nearest Emergency Department.