Tele-Optometry and Electronic Communication Consent Please read the Tele-Optometry pateint information Sheet_MEVC Tele-Optometry and Electronic Communication Consent Form Date* MM slash DD slash YYYY Patient Name* First Last Does the patient need a Subtitute Decision-Maker?* Yes No Name of Substitute Decision-Maker First Last On behalf of above named patientRelationship to patient (if applicable)*I Consent to receive Tele-Optometry Service by Markham Eye and Vision Care* I confirm that I, as the patient or substitute decision-maker on behalf of the patient☑have read the Tele-Optometry Patient Information Sheet and understand and accept the risks and limitations associated with the receipt of Tele-Optometry Services via the Tele-Optometry Technology; ☑have been advised of and understand the nature, material risks, consequences, side effects, expected benefits of and alternatives to the Tele-Optometry Services; ☑will abide by the Patient Responsibilities set out in the Tele-Optometry Patient Information Sheet, as well as any other terms and conditions required of me by the Optometrist in respect of the Tele-Optometry Services; ☑have had the opportunity to ask questions regarding the Tele-Optometry Services and have received answers to all of my questions; ☑understand that I may withdraw my consent to the Tele-Optometry Services at any time; and consent to receipt of the Tele-Optometry Services. ☑accept my signature by submitting this form electronically. Electronic Communication ConsentIn order for us to provide access to complete forms online, email receipts, and receive appointment reminders, and necessary communication content for your eye care services.Consent to Electronic Communications*With your consent, the Optometrist may communicate with you via text message, email or other forms of electronic communication (“Electronic Communications”) for administrative purposes such as appointment scheduling, confirmation and cancellation, and to provide information and consent forms, as well as information about services, programs and other offerings. Clinic service email including the following addresses: info@eyecaremarkham.com, eyedr.wang@gmail.com, markhameyeandvisioncare@gmail.com I agree to communicate with Markham Eye and Vision Care electronicallyEmail Address* Cell Phone Number*You can withdraw your consent to receive Electronic Communications at any time by contacting Markham Eye and Vision Care, Dr. Yilei Wang, Optometrist.This field is hidden when viewing the formTime : Hours Minutes AM PM AM/PM This field is hidden when viewing the formSignature*EmailThis field is for validation purposes and should be left unchanged. Δ
