Registration Form – Dr. Hall-Findlay – 2024

*Fields marked with an asterisk are mandatory and will need to be filled in for a successful submission.

**In accordance with Body Mass Index (click here to calculate your BMI) protocols, you must have a maximum BMI of 30.0 to have surgery

Banff Plastic Surgery Consents - Use of Personal Information and Electronic Communications

Personal Information

Privacy of your personal information is an important part of our office providing you with quality care.  We understand the importance of protecting your personal information.  We are committed to collecting, using and disclosing your personal information responsibly.

All staff members who come in contact with your personal information are aware of the sensitive nature of the information that you have disclosed to us.  They are all trained in the appropriate uses and protection of your information.

Attached to this consent form, we have outlined what our office is doing to ensure that:
-Only necessary information is collected about you;
-We only share your information with your consent; 
-Storage, retention and destruction of your personal information complies with existing legislation, and privacy protection protocols;
-Our privacy protocols comply with privacy legislation

How Our Office Collects, Use's and Discloses Patients’ Personal Information

Our office understands the importance of protecting your personal information.  To help you understand how we are doing that, we have outlined how our office is using and disclosing information.

This office will collect, use and disclose information about you for the following purposes:
-To deliver safe and efficient patient care
-To identify and to ensure continuous high quality service
-To assess your health needs and to provide health care
-To advise you of treatment options
-To enable us to contact you, and to establish and maintain communication with you to book and confirm appointments
-To process credit card payments
-To assist our office to comply with all regulatory requirements
-To comply generally with the law

By signing the consent section of this Patient Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes that are listed.  If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance.

You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision, and the process.

PATIENT CONSENT:

I have reviewed the above information that explains how Banff Plastic Surgery will use my personal information, and the steps that the office is taking to protect my information.
I know that the Banff Plastic Surgery office has a Privacy Code, and I can ask to see the Code at any time.
I consent to the collection, use and disclosure of my personal information, as set out above.

Electronic Communications

Consent to Use Electronic Communications

ELIZABETH J. HALL-FINDLAY, MD , FRCSC
YAEESH SARDIWALLA, MD, FRCSC
217-304 Old Canmore Rd (Shops of Canmore) 
Canmore AB, T1W 0L5
www.banffplasticsurgery.ca

The Physician has offered to communicate using the following means of electronic communications (“the Services”)
-EMAIL 
-WEBSITE/PORTAL 
-TEXT MESSAGING	

Patient Acknowledgement 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 rest of this consent form.  I understand and accept the risks outlined in the consent, 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 the communications with patients using the Services.  

I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for electronic communication, 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.  

APPENDIX
Risks of using electronic communication
 
The Physician and staff will use reasonable means to protect the security and confidentiality of information sent and received using Services (“Services” as defined above).  However, because of the risks outlined below, the Physician and staff 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 and staff 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.  

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 messages once it has been sent.  

Conditions of using the Services
-While the Physician and staff will attempt to review and respond in a timely fashion to your electronic communication, the Physician and staff 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 matter.
-If your electronic communication requires or invites a response from the Physician and staff 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 and staffs 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 vice versa and those involved in the delivery and administration of your care.  The Physician and staff might use one or more of the Services to communicate with those involved in your care.  The Physician and staff will not forward electronic communications to third parties, including family members, without your prior written consent, except as authorized or required by law.
-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 and staff are 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 and staff 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 and staff.
-Ensure the Physician and staff are aware when you receive an electronic communication from the Physician and staff, 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 and staff.  
-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.  

I have reviewed the above information and understand all of the risks, conditions, and instructions described in this Appendix in regards to Electronic Communications.

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