Email Consent Request

Please review the following email policy and submit consent below. Risks of using email Transmitting patient information poses several risks of which you should be aware. You should not agree to communicate via email without understanding and accepting these risks. The risks include, but are not limited to, the following:

  1. The privacy and security of email communication cannot be guaranteed.
  2. Employers and online services may have a legal right to inspect and keep emails that pass through their system.
  3. Email is easier to falsify than handwritten or signed hard copies. In addition, it is impossible to verify the true identity of the sender, or to ensure that only the recipient can read the email once it has been sent.
  4. Emails can introduce viruses into a computer system, and potentially damage or disrupt the computer.
  5. Email can be forwarded, intercepted, circulated, stored or even changed without the knowledge or permission of the UGFHT or the patient. Email senders can easily misaddress an email, resulting in it being sent to many unintended and unknown recipients.
  6. Email may be permanent. Even after the sender and recipient have deleted their copies of the email, back-up copies may exist on a computer or in cyberspace.
  7. Use of email to discuss sensitive information can increase the risk of such information being disclosed to others.
  8. Email can be used as evidence in court.
  9. Choosing not to use encryption software increases the risk of privacy violation.

Conditions of using email The UGFHT will use reasonable means to protect the security and confidentiality of email information sent and received. However, because of the risks outlined above, the security and confidentiality of email communication cannot be guaranteed. Thus, you must consent to the use of email. Consent for Patients Under Age 14 A parent/guardian may provide pediatric email consent on behalf of a child under 14 by confirming they have read and agree to the terms, and agree that communication with UGFHT via email is for the purpose of clinical care of the named child. The parent/guardian must provide their name, telephone number, relationship to the child, and the email address to be used.  The parent/guardian does not need to be a patient of UGFHT. Prior to the expiration of a pediatric email consent, the UGFHT will contact the parent/guardian and the patient with information on options for patients 14 and over.  If consent is not received from the patient to continue email communication with the original parent/guardian email, that email address will be removed. Please Note: E-mail should never be used in an emergency. IF YOU HAVE A MEDICAL EMERGENCY YOU SHOULD CALL 9-1-1 OR GO TO YOUR NEAREST EMERGENCY ROOM. ONLY USE THIS FORM to provide Email Consent or email address change  

Are you submitting this form on behalf of someone else?

14 + 15 =

Patient acknowledgment and agreement
By submitting this form I acknowledge that I have read and fully understand the UGFHT consent form. I understand the risks associated with the communication of email between the health provider and me, and consent to the conditions outlined herein, as well as any other instructions that the health care provider may impose to communicate with patients by email. I acknowledge the right of the UGFHT to, upon the provision of written notice, withdraw the option of communicating through email. Any questions I may have had were answered.

I agree that the Family Health Team and their physicians, staff, directors, officers and other agents shall not be responsible for any personal injury including death, and/or privacy breach (outside the reasonable control of the Family Health Team) or other damages as a result of my choice to communicate with the Family Health Team by email and I release the Family Health Team and their physicians, directors, officers and other agents from any liability relating to communicating with me by email.

Parents/Guardians – for patients under the age of 14
I acknowledge that I have read and agree to these terms on behalf of the above-named patient and wish to communicate with UGFHT for the purposes of their clinical care.  


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