Virtual Appointments Consent

Please scroll to the bottom to fill out the consent form

Attention Patients,

In keeping with our goal to reduce the risk of exposure to COVID-19 for our patients and staff, Cameron Medical will book Telemed visits to ANY patients with ONE OR MORE of the following:

Cold or flu-like symptoms
History of domestic or international travel for whatever reason in the past 2 weeks, either by airport or a border crossing
Age 65 years and older
Chronic health conditions or immune compromised (e.g. Rheumatoid Arthritis, asthma, Crohns, Lupus, or a cancer that is currently being treated)
Any patient who feels their health needs are better met by a telemedicine visit
Booking of Telemed appointments can be made by phoning the office during office hours and speaking with staff to set up a time to connect. We will be setting aside certain parts of our day for these appointments and will treat them as we do in office visits. As previously stated, we require that you read and sign the privacy and consent form to enrol in telemed visits.
If you do not wish to enrol, then we will arrange for a telephone call appointment instead and then decide on the next best step to manage your medical concern. Should further testing or evaluation in person be recommended, the appropriate medical service or visit will be arranged.
This new appointment process will be evaluated and adjusted to accommodate ongoing developments related to this new viral illness and your medical care.
Please be advised that we continue to strongly recommend that all patients abide by the up to date recommendations of the B.C. Public Health Officer, Dr. Bonnie Henry, which include: when to seek medical attention, when to quarantine, and when to self-isolate.
Please continue to wash your hands regularly and thoroughly with soap for 20 seconds, avoid touching your face, cough into your sleeve and practice social distance to do your part to support community efforts for the containment of Covid-19. Everyone of us has the responsibility to be mindful of doing their part in maintaining health and safety for all. Guidance for self-isolation is available on the BCCDC website: http://bccdc.ca

Click here to view the flyer
Click here for all COVID-19 FAQs and latest updates (from the BC Centre for Disease Control)
Please read below to register for the Virtual Appointments service.

Consent for Virtual Appointments

If you wish to enrol, please read and complete the consent form in full.

Consent for Electronic Communications.

Cameron Medical Physicians offering the service: Dr R Malhi, Dr A Buie, Dr I Gallo, Dr K Baker

Clinic Address: #240 - 9600 Cameron Street, Burnaby.V3J 7N3 Website: Cameronmedical.net Contact information (email/phone): This form was adapted from the CMPA Consent for Electronic Communications Form. PATIENT ACKNOWLEDGMENT AND AGREEMENT: I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of the selected electronic communication Services more fully described in the Appendix to this consent form. I understand and accept the risks outlined in the Appendix to this consent form, associated with the use of the Services in communications with the Physician and the Physician’s staff. I consent to the conditions and will follow the instructions outlined in the Appendix, as well as any other conditions that the Physician may impose on communications with patients using the Services. I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for electronic communications, it is possible that communications with the Physician or the Physician’s staff using the Services may not be encrypted. Despite this, I agree to communicate with the Physician or the Physician’s staff using these Services with a full understanding of the risk. I acknowledge that either I or the Physician may, at any time, withdraw the option of communicating electronically through the Services upon providing written notice. Any questions I had have been answered.

Your Name

First Name

Last Name

Your Child's Name

*Only required if you are completing this form for your child under the age of 16

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

The Physician has offered to communicate using the following means of electronic communication (“the Services”):

Choose the options that apply. To book a telehealth appointment you must consent to communication via videoconferencing.

Videoconferencing (Telehealth – Doxy.me)

Email (*not for medical advice, and not checked by health care professional)

Text Message (only used if required, not for medical advice)

Other - Please specify

APPENDIX Risks of using electronic communication

The Physician will use reasonable means to protect the security and confidentiality of information sent and received using the Services (“Services” is defined in the attached Consent to use electronic communications). However, because of the risks outlined below, the Physician cannot guarantee the security and confidentiality of electronic communications: • Use of electronic communications to discuss sensitive information can increase the risk of such information being disclosed to third parties. • Despite reasonable efforts to protect the privacy and security of electronic communication, it is not possible to completely secure the information. • Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system. • Electronic communications can introduce malware into a computer system, and potentially damage or disrupt the computer, networks, and security settings. • Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the Physician or the patient. • Even after the sender and recipient have deleted copies of electronic communications, back-up copies may exist on a computer system. • Electronic communications may be disclosed in accordance with a duty to report or a court order. • Videoconferencing using services such as Skype or FaceTime may be more open to interception than other forms of videoconferencing. If the email or text is used as an e-communication tool, the following are additional risks: • Email, text messages, and instant messages can more easily be misdirected, resulting in increased risk of being received by unintended and unknown recipients. • Email, text messages, and instant messages can be easier to falsify than handwritten or signed hard copies. It is not feasible to verify the true identity of the sender, or to ensure that only the recipient can read the message once it has been sent. Conditions of using the Services • While the Physician will attempt to review and respond in a timely fashion to your electronic communication, the Physician cannot guarantee that all electronic communications will be reviewed and responded to within any specific period of time. The Services will not be used for medical emergencies or other time-sensitive matters. • If your electronic communication requires or invites a response from the Physician and you have not received a response within a reasonable time period, it is your responsibility to follow up to determine whether the intended recipient received the electronic communication and when the recipient will respond. • Electronic communication is not an appropriate substitute for in-person or over-the-telephone communication or clinical examinations, where appropriate, or for attending the Emergency Department when needed.You are responsible for following up on the Physician’s electronic communication and for scheduling appointments where warranted. • Electronic communications concerning diagnosis or treatment may be printed or transcribed in full and made part of your medical record. Other individuals authorized to access the medical record, such as staff and billing personnel, may have access to those communications. • The Physician may forward electronic communications to staff and those involved in the delivery and administration of your care. The Physician might use one or more of the Services to communicate with those involved in your care. The Physician will not forward electronic communications to third parties, including family members, without your prior written consent, except as authorized or required by law. • You and the Physician will not use the Services to communicate sensitive medical information about matters specified below: Sexually transmitted disease, AIDS/HIV, Mental health, Developmental disability, Substance abuse • You agree to inform the Physician of any types of information you do not want sent via the Services, in addition to those set out above. You can add to or modify the above list at any time by notifying the Physician in writing. • Some Services might not be used for therapeutic purposes or to communicate clinical information. Where applicable, the use of these Services will be limited to education, information, and administrative purposes. • The Physician is not responsible for information loss due to technical failures associated with your software or internet service provider. Instructions for communication using the Services To communicate using the Services, you must: • Reasonably limit or avoid using an employer’s or other third party’s computer. • Inform the Physician of any changes in the patient’s email address, mobile phone number, or other account information necessary to communicate via the Services. If the Services include email, instant messaging and/or text messaging, the following applies: • Include in the message’s subject line an appropriate description of the nature of the communication (e.g. “prescription renewal”), and your full name in the body of the message. • Review all electronic communications to ensure they are clear and that all relevant information is provided before sending to the physician. • Ensure the Physician is aware when you receive an electronic communication from the Physician, such as by a reply message or allowing “read receipts” to be sent. • Take precautions to preserve the confidentiality of electronic communications, such as using screen savers and safeguarding computer passwords. • Withdraw consent only by email or written communication to the Physician. • If you require immediate assistance, or if your condition appears serious or rapidly worsens, you should not rely on the Services. Rather, you should call the Physician’s office or take other measures as appropriate, such as going to the nearest Emergency Department or urgent care clinic.

Consent:

To proceed with a Videoconference medical visit the patient must consent to the terms as outlined (or the parent/guardian of the patient, if the patient is under the age of 16).

Patient Signature (parent/guardian)

Please type your name below

Book a Virtual Appointment

To book a virtual appointment please call the clinic at (604) 421-1027 and inform the staff you have completed the consent form via our website.

At the time of your appointment you may click the button below to join the virtual waiting room. We advise doing this 5 minutes before your scheduled appointment.

Click here to begin your scheduled Virtual Appointment >