Email Consent

Below is the full wording for our email consent form for your reference. Please connect with your care team for more information.

CONSENT FOR USE AND CANCEL USE OF ELECTRONIC INFORMATION – EMAIL and/or TEXT COMMUNICATION

KidsInclusive – Kingston Health Sciences Centre at Hotel Dieu Hospital (HDH) is committed to protecting your child’s personal health information. Traditionally we communicate with families by regular mail, fax and phone, however, email/text communication is becoming the preferred method of communication for many clients/families (texting is only allowed on KHSC issued mobile phones and is only used to confirm appointment times). Please review the following information carefully before providing consent for KidsInclusive to use email/text as a form of communication with you. If you have any questions, please do not hesitate to ask your service provider.

• I understand that electronic communications may not be encrypted outside of the hospital email system, and security and privacy can never be completely guaranteed. I may also have information that I would prefer not to be discussed in email or text messages, and I will consider other ways to communicate more sensitive and confidential information with KidsInclusive should I wish to.
• I understand that email or text communication/contents may be retained as part of the electronic client record and becomes the property of KidsInclusive.
• I understand that in signing this form I am providing KidsInclusive – Kingston Health Sciences Centre permission and my full consent to communicate with me via email or text. I understand that I can withhold or place conditions upon my consent without concern of reprisal. I understand that this consent remains effective unless revoked by me in writing, or until my child is discharged from the KidsInclusive. I understand that the withdrawal of consent shall not have retroactive effect.

I have read (or been read to) the above information and have had the opportunity to ask and have answered any questions. I understand that by signing this form I am consenting to email/text communication with KidsInclusive as outlined above: (circle one) YES / NO

Date:
Relationship to client:
Print Name of individual providing/declining consent:
Signature of individual providing consent (if written):
□ Verbal consent Obtained by:
Email address and/or mobile number:
Client / Family requested limitations for email or text:

KidsInclusive uses email to send news and surveys related to KidsInclusive. I consent to receiving these emails: (circle one) YES / NO