Flu Shot Available Now
Home
About Us
Services
Virtual Care
Family Practice and Walk-In
Children and Baby
Immunizations
WSIB
On-Site Lab
Doctors to Canada
Resources
MedChart
Contact Us
Menu
Home
About Us
Services
Virtual Care
Family Practice and Walk-In
Children and Baby
Immunizations
WSIB
On-Site Lab
Doctors to Canada
Resources
MedChart
Contact Us
Contact Us
General, Family Practice
& Walk-in Form
Name
Email
Message
Send
Electronic Communication Consent Form
First Name
Last Name
Physician's Name
Email Address
Date:
*PATIENT ACKNOWLEDGEMENT AND AGREEMENT: I acknowledge that I have read and fully understand the Email Policy. I understand the risks associated with the use of communication by email between the Physician and me, and consent to the conditions outlined herein, as well as any other instructions that the Physician may impose to communicate with patients by e-mail. I acknowledge the Physician’s right to, upon the provision of written notice, withdraw the option of communicating through e-mail.
Send
