CONSENT TO USE PATHWAYS ELECTRONIC COMMUNICATIONS

SUKHMAN MEDICAL CLINIC.

106-12025 NORDEL WAY

SURREY, BC, V3W1W1

IMPORTANT: This consent form, once signed by you, will allow your Physician and his or her

office staff to communicate certain types of personal and/or health information

electronically to: (a) you; and (b) Consultants (including Specialist Physicians) and their office

staff. It also allows the Specialists/Consultants and their office staff to communicate through

Pathways with: (a) you; and (b) your Physician and his or her office staff (collectively,

“Communications”). When you sign this form, you are agreeing that you have read,

understood and accepted the conditions below. Some of these conditions may impact your

rights. Please read this form carefully and if you do not agree with anything, do not sign it.

Pathways is an online resource that allows referring physicians and their office staff (“Physicians”) to quickly access current and

accurate referral information, including wait times and areas of expertise, for specialists/consultants and specialty clinics and their

staff (“Specialists/Consultants”). It helps your Physician to send and track referrals, helps Specialists to track referrals, and allows

Specialists and referring Physicians to communicate with each other, notify patients of their upcoming appointments and

appointment changes, and send reminders to patients. Your Physician and Specialist/Consultant have offered to use Pathways to

communicate referral information between themselves and their offices and you using electronic communication (the “Services”).

Please indicate below how you would prefer to receive electronic notifications about appointments and include your contact details.

Please select ONE only:

PATIENT ACKNOWLEDGEMENT AND AGREEMENT:

• I acknowledge that email and text communication do not provide a completely secure means of communication and that these communications may be misdirected, resulting in increased risk of being received by unintended and unknown recipients

• I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for electronic communications, it is possible that the Communications may not be encrypted. Despite this, I agree to allow such Communications with a full understanding of the risk.

• I acknowledge that either I or the Physician or the Specialist/Consultant may, at any time, withdraw the option of communicating electronically (or I may change what information I consent to being sent through the Services), upon providing written notice.

• I acknowledge and agree that the Physician may forward electronic communications containing referral information to staff and those involved in the diagnosis, delivery or administration of my care without further written consent, and to others as authorized or required by law.

• I agree to inform the Physician of any types of information that I do not want sent via the Services.

• I acknowledge that neither the Physician nor the Specialist/Consultant is responsible for information loss due to technical failures associated with my software or internet service provider.

• I agree to inform the Physician promptly of any changes in my email address, mobile phone number, or other account information necessary for Communications via the Services.

• I have been provided with sufficient time to review this consent form and any questions I had have been answered. I understand that I may ask additional questions at any time.