To give consent, please fill in this form and press Submit.
YES, I, the patient, give consent to communicate and receive care using virtual and other telecommunications tools with Omineca Medical Clinic. I have read and understand the risks related to unauthorized disclosure or interception of personal health information and steps I can take to help protect my information. I understand that care provided through video or audio communication cannot replace the need for physical examination or an in person visit for some disorders or urgent problems and I understand the need to seek urgent care in an Emergency Department as necessary.
The Patient:
First Name:
Surname:
Date of Birth:
Phone Number:
Email:
Mailing Address:
The person giving consent for the patient named above is the:
Patient Parent/Guardian Representative/Committee TSDM (Temporary Substitute Decision Maker)
Name of person giving consent:
