Thank you for visiting PRP Medical Aesthetics.  This intake form will help us understand and achieve your goals together.  Thank you for taking the time to complete it. 

The second part of this form is optional, Virtual Care Consent, which is necessary for us to communicate with you by email, text messages, etc.

This form outlines the risks, limitations, conditions of use and instructions for using virtual care tools in the communication between you as the patient and PRP Medical Aesthetics and its health care providers, including Dr. Patrick Yam, ("The Physician").

This form is intended as a basis for discussion.  Please feel free to ask any questions you may have regarding the use of virtual care tools. 

The APPENDIX below outlines the main risks, limitations, conditions of use and instructions for using the Services.  Please take time to read it carefully and ask any questions you may have before making your decision regarding the use of the Services.

The Physician has offered to provide the following means of virtual care ("The Services"):  Email, Text Messaging (eg. WhatsApp, SMS), Videoconferencing (e.g. Zoom calls), and other virtual means which may be possible.

Risks of using virtual care tools

The Physician will use reasonable means to protect the security and confidentiality of information sent and received using the Services (“Services” is defined in the attached Consent to use virtual care tools). However, because of the risks outlined below, the Physician cannot guarantee the security and confidentiality of all virtual care tools:
• Use of virtual care tools to discuss sensitive information can increase the risk of such information being intercepted by third parties.
• Despite reasonable efforts to protect the privacy and security of information communicated through virtual care platforms, 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.
• Virtual care tools can introduce malware into a computer system, and potentially damage or disrupt the computer,networks, and security settings.
• Communications through virtual care tools can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the Physician or the patient.
• Even after the sender and recipient have deleted copies of electronic communications, back-up copies may exist on a computer system.
• Communications through virtual care tools may be disclosed in accordance with a duty to report or a court order.
• Some videoconferencing platforms may be more open to interception than other forms of videoconferencing.

If the email or text is used as a virtual care 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 message once it has been sent.

Conditions of using the Services

While the Physician will attempt to review and respond in a timely fashion to electronic communications such as emails, text messages, and instant messages, the Physician 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 matters.
• If your electronic communication requires or invites a response from the Physician 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.
• Virtual care 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’s electronic communication and for scheduling appointments where warranted.
• Electronic communications or recordings of virtual encounters 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 and recordings.
• The Physician may forward electronic communications or recordings to staff and those involved in the delivery and administration of your care. The Physician might use one or more of the Services to communicate with those involved in your care. The Physician will not forward electronic communications or recordings to third parties, including family members, without your prior written consent, except as authorized or required by law.
• You and the Physician will not use the Services to communicate sensitive medical information about the following matters unless mutually agreed upon: Sexually transmitted disease, AIDS/HIV, Mental health, Developmental disability, Substance abuse
• You agree to inform the Physician of any types of information you do not want sent via the Services, in addition to those set out above. You can add to or modify the above list at any time by notifying the Physician in writing.
• 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 is not responsible for information loss due to technical failures associated with your software or internet service provider. 

Terms and Conditions for using the Services:

To use the Services, you must:
• Reasonably limit or avoid using an employer’s or other third party’s computer.
• Conduct virtual care encounters in a private setting and using a secure device, where possible.
• Obtain the Physician’s consent prior to making any recording of the virtual care encounter.
• Inform the Physician 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.
• Ensure the Physician is aware when you receive an electronic communication from the Physician, 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.
• 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.

PATIENT ACKNOWLEDGMENT AND AGREEMENT

I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of the selected Services more fully described in the Appendix to this consent form. I understand and accept the risks outlined in the Appendix to this consent form, associated with the use of the Services when interacting 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 in relation to patients using the Services.

I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for virtual care tools, it is possible that interacting with the Physician or the Physician’s staff using the Services may not be encrypted. Despite this, I agree to interact 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 using the Services upon providing written notice. Any questions I had have been answered.

COST OF SERVICES

I agree to be responsible for and pay for all charges incurred for virtual care services. All fees are subject to change without notice.  Current charges include:

1.  Email consultation:  $300 per hour of physician's time, with a minimum of $75.  If you require a response to your email from our physician, it will be consider a consultation and a minimum $75 fee per email will be charged.  If you are updating us or do not require a response, no fee will be charged. This fee does not apply to Doctor to Doctor communication in regards to a mutual patient.  This fee is subject to change without notice.

2. Prescription refills:  $35 for calling in or faxing a refill prescription to a pharmacy.

3.  Other charges: Other charges for forms, paperwork, letters to be determined on an individual basis.