Consent Form - Patients
Boutique Medicine Ltd.
SECTION 1 – Patient Information (refer to Welcome Patient Questionnaire)
SECTION 2 - Introduction
You have been asked to provide your consent to the terms of this consent form (the “Form”) because you have expressed an interest in receiving medical care (“Medical Care”) from a physician (the “Physician”) affiliated with Boutique Medicine Ltd. (“Boutique Medicine”).
Boutique Medicine operates an electronic platform (the “Platform”) to assist the Physician in providing you with Medical Care. The Platform facilitates consultations between you and the Physician, for example by providing booking, billing, and medical record maintenance services (the “Platform Services”). The Medical Care is provided exclusively by the Physician, and not by Boutique Medicine. Boutique Medicine is not a party to the professional relationship between you and the Physician.
Because the nature of the Medical Care depends on your individual needs, the Physician will seek your consent to specific interventions as the need arises in accordance with current professional standards. The purpose of this Form is to document your consent to the Physician’s use of the Platform Services in providing Medical Care.
SECTION 3 – Collection, Use, Disclosure and Processing of your Medical Information
The Physician may collect Medical Information directly from you as part of a consultation, and from other custodians of your healthcare records, such as healthcare professionals, institutions or providers and administrative databases.
Boutique Medicine will use your Medical Information exclusively to provide the Platform Services. The Physician will use your Medical Information exclusively to provide the Medical Care.
If the Physician is not available to provide Medical Care at a scheduled appointment, Boutique Medicine may allow another physician affiliated with Boutique Medicine to have access to your Medical Information to provide Medical Care. The other physician is bound by the same obligations of confidentiality as the Physician.
Your Medical Care may require that your Medical Information be disclosed to a third party, for example, if you are referred to a hospital for further examinations. If that is the case, the Physician will seek and document your consent to such disclosure separately.
Except where permitted or required by law and except as described above, neither Boutique Medicine nor the Physician will disclose your Medical Information to any third party without your consent. The Physician may notably be required by law to disclose your Medical Information if situations of child abuse, or imminent risk of violence or suicide are discovered.
Boutique Medicine will retain your Medical Information for the period required by applicable law, after which it will be destroyed.
SECTION 4 – Aggregate Data
“Aggregate Data” is general information about groups of patients and/or professionals and does not identify individuals. Boutique Medicine may combine your information with that of other patients or professionals to generate Aggregate Data that can be used to improve the Platform Services or develop new services.
SECTION 5 - Conflict of Interest Disclosure
Dr. Ziad Azzi, one of the Physicians affiliated with Boutique Medicine is also a shareholder of Boutique Medicine. Dr. Azzi contributed to the development of the Platform and may make a profit from the use of the Platform Services. However, Dr. Azzi does not make any profit from the sale of any medications or other products that you may receive or be prescribed because of the Medical Care. By providing your consent, you acknowledge having been informed of the foregoing.
SECTION 6 – Patient Consent
By consenting, you authorize all custodians of your healthcare records to disclose your Medical Information as necessary to Boutique Medicine and the Physician. This includes, but is not limited to information relating to your past and present medical condition(s), treatment, care management, and health insurance.
Currently, your Medical Information will be stored in Canada. However, in the future, it may be stored or processed in any other jurisdiction in which Boutique Medicine has facilities, or in which Boutique Medicine uses the services of a third party. In this case, your Medical Information may be transferred to such jurisdictions, and their rules respecting the privacy protection may differ from those of Canada. If your Medical Information is stored in a country other than Canada, it may be subject to the laws of that country and could be disclosed to the government, the courts, or law enforcement agencies of that country in accordance with local laws. However, your Medical Information will remain subject to this Form and to applicable law.
Whether your Medical Information is stored or processed inside or outside of Canada, Boutique Medicine will ensure that your Medical Information is protected by reasonable technical, physical, and administrative safeguards to protect it against loss, theft, and unauthorized consultation, communication, copying, use or alteration. Only the Physician and authorized employees, agents and mandataries of Boutique Medicine may be given access to your Medical Information where necessary for the purposes described in this Form.
If you have any questions about this Form, you may contact our Privacy Officer at email@example.com. You may request access to or correction of your Medical Information at any time by contacting Boutique Medicine’s Privacy Officer at the same address. You may also withdraw your consent to the collection, use and disclosure of your Medical Information under the terms of this Form at any time by contacting Boutique Medicine’s Privacy Officer at the same address. However, it will not be possible to continue providing you with Medical Care if you withdraw your consent.
By clicking below, you confirm that you have read and understood this Form, that you had an opportunity to ask questions about it and that you agree to the collection, use and disclosure of your Medical Information in accordance with the terms contained herein. You acknowledge and agree that clicking below is legally equivalent to signing this Form on paper.