Alliance MDS

Name: *

As it is listed on your health card.

First Name

Last Name

Is your Primary Phone a cell phone? *

Yes

No

Is your primary phone number the ONLY number our office should use to contact you? *

By checking yes, you acknowledge we will be deleting all other previous/different phone numbers from your file. Note: If you are also a patient of a Magenta Health physician, your file there will automatically be updated as well.

Yes

No

Secondary Phone Number (if applicable)

(###)

###

####

Current Address: *

Your address MUST match the address on file with the Ministry of Health (i.e. the same address registered to your health card)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

I have already scheduled an intake appointment for ... : *

Only individuals with who have booked an intake appointment should complete this form. Any other submissions will be deleted immediately without review.

MM

DD

YYYY

Email Consent: *

We use email as a fast, clear, and largely reliable way of communication. May we include health information when emailing you? Sample messages that include health information would be messages to ask you to book a follow-up appointment, to let you know your results are normal, or to share details of a referral to a third-party. For clarity, we do not send marketing newsletters or sell your email address to third parties. Please see below for a discussion of the risks, conditions, and instructions for email. *Email Communication* Risks of using email Transmitting patient information by email poses several risks of which patients should be aware. You should not agree to communicate with us via email without understanding and accepting these risks. The risks include, but are not limited to, the following: - The privacy and security of email communication cannot be guaranteed. - Employers and online services may have a legal right to inspect and keep emails that pass through their system. - Email is easier to falsify than handwritten or signed hard copies. In addition, it is impossible to verify the true identity of the sender, or to ensure that only the recipient can read the email once it has been sent. - Emails can introduce viruses into a computer system, and potentially damage or disrupt the computer. - Email can be forwarded, intercepted, circulated, stored or even changed without our knowledge or permission. - - Email senders can easily misaddress an email, resulting in it being sent to many unintended and unknown recipients. - Email is indelible. Even after the sender and recipient have deleted their copies of the email, back-up copies may exist on a computer or in cyberspace. - Use of email to discuss sensitive information can increase the risk of such information being disclosed to third parties. - Email can be used as evidence in court. *Conditions of using email* We will use reasonable means to protect the security and confidentiality of email information sent and received. However, because of the risks outlined above, we cannot guarantee the security and confidentiality of email communication. Thus, patients must consent to the use of email for patient information. Consent to the use of email includes agreement with the following conditions: -Emails to or from the patient concerning diagnosis or treatment may be made part of the patient’s medical record. Because they are part of the medical record, other individuals authorized to access the medical record, such as staff and billing personnel, will have access to those emails. - Email communication is not an appropriate substitute for clinical examinations. The patient is responsible for following up with our emails and for scheduling appointments where warranted. - If the patient’s email requires or invites a response from us and the patient has not received a response within a reasonable time period, it is the patient’s responsibility to follow up to determine whether the intended recipient received the email and when the recipient will respond. - We are not responsible for information loss due to technical failures associated with the patient’s email software or internet service provider. * Instructions for communication by email* To communicate by email, the patient shall: - Limit or avoid using an employer’s or other third party’s computer. - Review the email to make sure it is clear and that all relevant information is provided before sending to us, including the purpose of the email and the name of the patient. - Take reasonable precautions to preserve the confidentiality of emails. - Withdraw consent only by email or written communication to us.

Yes

No

Kindly review and acknowledge the following (Risks Involved With Virtual Appointments): *

Some appointments with the physician may be conducted using video, rather than in-person.  Some health concerns can be addressed with virtual care alone, but in some cases your doctor may ask you to visit a hospital or other health care facility if necessary, for a physical examination. We do our best to make sure that any information you give to us during virtual care visits is private and secure, but no video or audio tools are ever completely secure. There is an increased security risk that your health information may be intercepted or disclosed to third parties when using video or audio communications tools. To help us keep your information safe and secure, you can: - Understand that emails, calls, or texts you receive are not secure in the same way as a private appointment in an exam room.  - Use a private computer/device (i.e., not an employer's or third party's computer/device), secure accounts, and a secure internet connection.  For example, using a personal and encrypted email account is more secure than an unencrypted email account, and your access to the Internet on your home network will generally be more secure than an open guest Wi-Fi connection. You should also understand that electronic communication is not a substitute for in-person communication or clinical examinations, where appropriate, or for attending the Emergency Department when needed (including for any urgent care that may be required). If you are concerned about using video or audio tools for virtual care, we can let your referring doctor know that you would like to visit a different healthcare provider where you can be seen in person. However, please note that visiting a health care provider in person comes with a higher risk of coming into contact with COVID-19 and the possibility of spreading the virus. By providing your information, you agree to let us collect, use, or disclose your personal health information through video or audio communications (while following applicable privacy laws) in order to provide you with care.  In particular, the following means of electronic communication may be used: email, videoconferencing, text messaging, website/portal.

Yes (I have reviewed and acknowledged the above)

Kindly review and acknowledge the following (Dr. Johnny Wong is not a Magenta Physician): *

1. Magenta Health Inc. ("MHI") is a medical management company that owns and operates one or more clinics under the brand name MAGENTA HEALTH (the "Magenta Health Clinics"). 2. MHI is not permitted to, nor does it, provide medical services to patients, including myself. 3. Physicians practicing at Magenta Health Clinics (such as the physician you are here to see today) are qualified independent medical practitioners providing medical services to patients directly, or via a medicine professional corporation as authorized under the laws of the Province of Ontario. 4. Physicians practicing at Magenta Health Clinics may receive some administrative assistance or support, but for the most part, operate their own practice. 5. If I consented to email communication, I have read and understood the attached discussion of the risks of email communication. 6. I understand that I will be contacted via the information above and confirm that my contact information is correct and up-to-date.

Yes ( I have reviewed and acknowledge the above)

Kindly review and acknowledge the following (Switching Providers): *

I agree to cancel my appointment(s) if I have found another healthcare provider to prescribe hormones while waiting for my appointment(s). I understand it is currently not possible to switch from another healthcare provider for gender-affirming hormone therapy due to the long wait times for other patients.

Yes (I have reviewed and acknowledge the above)

Are you pregnant or planning to be soon? *

Yes

No

N/A

If applicable, for any conditions selected above, I acknowledge that they are precautions/contraindications to gender-affirming hormone therapy and I have discussed them with my primary care provider to optimize management which may help minimize delays to starting gender-affirming hormone therapy. If any selected precautions/contraindications have not yet been assessed by my primary care provider, I understand I may have to reschedule my second intake appointment: *

Yes (I have reviewed and acknowledge the above)

Do you have concerns about being intersex (if yes, you will need to have your primary care provider redirect your referral to a physician who specializes in these conditions)? *

Yes

No

I understand this form will NOT be reviewed by a medical professional prior to my scheduled appointment: *

Yes

I understand I will not be a patient until after my appointment has been completed: *

Yes

I understand Dr. Wong does not provide family medicine or primary care services: *

Yes