Physiotherapy Service Provider Information

Name of Clinic: KINESIS PHYSIOTHERAPY AND REHABILITATION CENTRE

Address: 80 THICKSON RD SOUTH, WHITBY, L1N 7T2

Email: admin@kinsesisrehab.ca

Phone (as required for Service(s)): 905-493-9199

I, _____________________________________________, acknowledge that in consenting to have ______________________________________________ communicate with and/or provide physiotherapy services through email, text, social media, videoconferencing, etc.

• 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.

• 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 are subject to disruptions beyond the control of the Service Provider that may prevent the Service Provider from being able to provide services.

• Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the Service Provider 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.

• There may be limitations in the services that can be provided through electronic communications, dependent on the means of electronic communications being utilized.

• 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.

• While the Service Provider will endeavour to review electronic communications in a timely manner, the Service Provider cannot provide a timeline as to when communications will be reviewed and responded to. Electronic communications will not and should be used for medical emergencies or other time-sensitive matters.

• Electronic communication may not be an appropriate substitute for some services that the Service Provider offers.

• Prior to the commencement of the provision of services by the Service Provider through electronic communications, the Service Provider and the patient will establish an emergency protocol to address the following:

  • Steps to be followed in the event of a technical issue that causes a disruption in the services that are being provided by the Service Provider; and

  • Steps to be followed in the event of a medical emergency that occurs during the provision of services

• Steps to be followed in the event of a medical emergency that occurs during the provision of services

• The Patient will inform the Service Provider of any changes in the patient’s email address, mobile phone number, or other account information necessary to communicate electronically.

• The Patient will ensure the Service Provider is aware when they receive an electronic communication from the Service Provider, such as by a reply message or allowing “read receipts” to be sent.

• The Patient will take precautions to preserve the confidentiality of electronic communications, such as using screen savers and safeguarding computer passwords

• If the Patient no longer consents to the use of electronic communications by the Service Provider, then the Patient will provide notice of the withdrawal of consent by email or other written communication.

I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of the selected electronic communications as described above. I understand and accept the risks outlined above associated with the use of electronic communications with the Service Provider and the Service Provider’s staff. I consent to the conditions set out above and will follow the instructions set out above, as well as any other conditions that the Service Provider may impose regarding electronic communications with patients. I acknowledge and agree to communicate with the Service Provider or the Service Provider’s staff using electronic communications with a full understanding of the risks in doing so. I confirm that any questions that I had regarding the provision of physiotherapy services through electronic communications have been answered by the Service Provider.