Intake Form and Informed Consent

PERSONAL INFORMATION

EMERGENCY CONTACT

I hereby consent to the University of Regina contacting my emergency contact in the event of a medical emergency.

CONSENT TO INVESTIGATION, TREATMENT OR PROCEDURE

I hereby consent to undergo such investigations, treatments, tests or procedures as in the opinion of the Nurse Practitioner at the SWC are necessary and appropriate. I further agree to the examination and/or retention by the SWC and/or a consulting laboratory of any fluids or tissue that may be removed during the tests / procedure(s) for study and diagnosis. I further agree that in his or her discretion, the Nurse Practitioner may make use of the assistance of other medical or nursing staff (including trainees) and may permit them to order or perform all or part of the investigation, treatment, or procedure, and I agree that they shall have the same discretion in my investigation and treatment as the Nurse Practitioner.

CONSENT TO COMMUNICATION

As the privacy and security of email and text message communication cannot be guaranteed, such messages sent to you shall contain administrative or non-sensitive information only. Email or text messaging may be used to send you: information about booked or cancelled appointments; immunization forms (as requested by you); requests for you to contact the SWC; health promotion material; and other educational resources deemed relevant by your care providers. Email or text messages may become part of your confidential records within the SWC. It is your responsibility to ensure we have your correct email address and phone number.

I understand and accept that the privacy and security of email and text message communication cannot be guaranteed. I hereby consent to receiving administrative and non-sensitive information by email and text.

CONFIDENTIALITY AND SHARING OF INFORMATION

The SWC will be collecting your personal information (PI) and personal health information (PHI) within the meaning of The Local Authority Freedom of Information and Protection of Privacy Act (LAFOIP), and The Health Information Protection Act (HIPA), respectively, for the purpose of providing you with primary care services (the "Services"). HIPA and LAFOIP describe the rights you have with respect to your PI and PHI throughout your care at the SWC.
You have the right:

• to decide whether to consent to the use and disclosure of your PI/PHI. There are exceptional circumstances in which consent is not required;
• to revoke consent to the use or disclosure of your PI/PHI;
• to "mask" or lock your electronic medical record, or portions thereof, and make it inaccessible to care providers other than your own;
• to be informed about anticipated uses and disclosures of your PI/PHI;
• to be informed of disclosures of your PI/PHI without consent;
• to access PI/PHI about yourself;
• to request amendments to your record;
• to request a review by the Information and Privacy Commissioner or appeal to a court;
• to designate another person to make decisions about your PI/PHI.

There are situations in which it may be necessary to share your PI/PHI without your consent. In the event that your PI/PHI must be shared, only the minimum amount of information necessary to resolve the situation would be communicated. These situations are described below:

1. Where, in the judgment of the staff of the SWC, there is a serious risk to the health and safety of yourself, other members of the University community or the community at large, some of your PI/PHI may be shared with appropriate parties in order to ensure your safety or that of others. In such instances, the nature and detail of the information shared would depend on the specific circumstances;
2. If there is suspected neglect or harm to a child (physical, sexual, verbal and/or emotional), the Nurse Practitioner is legally obligated to share such information with relevant authorities in order to protect the child(ren) involved; or
3. Where otherwise required by law, or by a court order.

CONSENT TO USE AND DISCLOSURE OF PI / PHI

Other than with my express written consent, all PI and PHI obtained by the Clinic will be used or disclosed only as described below.

In signing this document, I consent to the use and disclosure of my PI and PHI as follows:

1. by SWC staff in the course of assessment, testing, prescribing and delivering the Services;
2. to my other relevant health care provider(s), and administrative staff on a "need to know" basis;
3. as required or permitted by law.

I also hereby consent to the University obtaining such PI / PHI from other health care providers as may be required in order to perform the Services.

CLIENT FILE MAINTENANCE AND RETENTION

Your PI and PHI will be entered into and retained in:

1. The Clinic’s electronic records on a secure server with Information Services at the University;
2. An electronic medical record maintained by The Saskatchewan Health Authority through the MedAcess system (the "EMR");
3. the eHealth Viewer provided through eHealth Saskatchewan.

Authorized SWC staff will be entitled to access and use your PI/PHI that is maintained in the EMR and the eHealth Viewer. The information in the Clinic electronic record will be maintained for 7 years following the date of the last Services provided to you, as required by legislation. I understand that I have a right to access my client file information during or after Services have ended.

I have read and understand the above information.

I have been provided an opportunity to ask questions.

I understand that my consent will be valid and in effect during the time that I am enrolled at the University of Regina.

I understand that I may withdraw this consent at any time by making written notice to one of my care providers.

I hereby consent to collection, use and disclosure of my PI / PHI as explained in this form.

Yes, I Agree to the terms and conditions set out above