Treatment consent form

I hereby consent to authorize the physicians of CEDAR CARE CLINIC to access my health information recorded elsewhere including the following:

1 - PharmaNet medication profile
2 - Health registry demographics
3 - Diagnostic health history

I hereby agree that:

a) All aspects of the relationship between me and the physicians of Cedar Care Clinic (as well as his/her agents, delegates, employees, and any physicians and other independent health care practitioners providing medical or other health care and treatment to me, or in association with the physicians of Cedar Care Clinic including without limitation any medical or other health care and treatment provided to me, and
b) The resolution of any and all disputes arising from or in connection with that relationship, including and disputes arising under or in connection with this agreement, shall be governed by and construed in accordance with the laws of the Province of British Columbia and the laws of Canada applicable therein.

I hereby acknowledge that the medical or other health care and treatment I receive from the physicians of Cedar Care Clinic will be provided in the province of British Columbia and that the courts of the province of British Columbia all have exclusive jurisdiction to hear any complaint, demand, claim, proceeding or cause of action, whatsoever arising from or in connection with that medical or other health care and treatment, or from any other aspect of my relationship to the physicians of Cedar Care Clinic.

I am aware that with respect to test results, Cedar Care Clinic generally does not give results over the phone. I am aware that if a test result requires further discussion, Cedar Care Clinic will contact me. If I have a concern regarding my medical condition especially if my symptoms have worsened, I am aware that it is important for me to see a doctor for follow-up regardless of whether I have been called in to discuss the results from a test.

I am aware that the medical services plan does not cover all services namely the filling out of insurance forms, driver's and sports medicals, and doctor's notes. I am aware the fees for this are posted at the front reception counter.

I am aware that I am to inform the medical staff if I would like records sent to another physician, including my family physician.