Required Forms Before Your Visit

Please complete the following forms before your appointment. These consents ensure we can provide safe, accurate, and efficient care during your visit.

Email Consent Form:

By providing us with your email address you have consented to our use of the contact information. There are times your personal health information will be sent via unencrypted email, if you make a request via email.

What we use your email for:

We may share your email information with other health care providers who are providing you with health care.
We may use your email to keep you informed of your referral status when you have been referred to another health care provider.
We may use your email to send you information about online health care programs (e.g. patient portals or opportunity to participate in virtual visits with Dr Machat).
We may use your email to send you information about changes in our clinic hours, holidays hours as well as changes in Dr Machat schedule.

Our responsibility:

We will only share your email with other health care providers directly involved with your care or our participating partners that are helping deliver online health care programs.
To protect your personal health information, we will not communicate with you via unencrypted email to discuss personal health information, unless you have provided us with consent.

Risks of using electronic communication:

We will use reasonable means to protect the security and confidentiality of information sent and received using email. However, because of the risks outlined below, and that we email not through a secure platform at times, we cannot guarantee the security and confidentiality of electronic communications:

Use of electronic communications to discuss sensitive information can increase the risk of such information being disclosed to third parties.
Despite reasonable efforts to protect the privacy and security of electronic communication, it is not possible to completely secure the information.
Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system, within and outside of Canada.
Electronic communications can introduce malware into a computer system, and potentially damage or disrupt the computer, networks, and security settings.
Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the Physician or the patient.

Due to the sensitivity of the information, we recommend that you do not use a shared email.

Patient Information

Please enter the following information as it appears on your health card

First name

Last name

Birthday

Year

Month

Day

Health Card Number

10 digits, no spaces and no version code

I hereby authorize Machat Medical and Menopause Clinic to disclose my personal health information to me via the following e-mail

Patient Consent for Use of AI Scribe:

Our clinic is using new artificial intelligence (AI) solution called an AI scribe. It is a technology that helps us

during patient visits by preparing notes based on our conversations with you. This allows doctors to focus more on patients and less on taking notes.

What is an AI Scribe?

An AI scribe is an application that makes a temporary audio recording and transcript of your discussion and creates a draft summary “note” for your doctor based on your conversation. This note will be reviewed and edited as needed by your doctor and becomes part of your electronic medical record.

How will this affect you?

If you agree, your doctor will begin using the AI scribe at the start of your visit. Based on the conversation, the AI scribe will create a summary note of the conversation. The AI scribe does not make decisions about your

care - it only summarizes your conversation and the observations your doctor has made. After your visit, your doctor will review information drafted by the AI scribe to make sure it is accurate and complete.

Privacy AI scribe vendors must comply with Ontario’s privacy laws and other legal requirements in order to safeguard your personal health information. No personal health information is used to train or improve any AI model. The AI scribe solution uses encryption to communicate with an AI model to protect personal health information. There is temporary data storage by the vendors outside of Canada. Once your doctor approves the final note, it is pasted in your electronic medical record. We have required that any temporary audio recording and transcript are securely deleted once the note is edited and finalized by

your doctor.

Risks Associated with AI Scribes

While safeguards are in place to protect your personal health information and comply with Ontario’s privacy laws, there are always some risks. These include possible inaccuracies in documentation, including how

information is captured or processed, biases, or misuse of data despite safeguards. Biases in AI tool outputs can result when the language model is trained on dataset which contain inherent biases (such as algorithmic or cognitive biases), or because the data used is not sufficiently diverse,

representative, or to the best extent possible, free of errors. Your personal health information is protected under Ontario’s privacy laws (PHIPA), and our clinic is committed to maintaining the security, accuracy, and confidentiality of your information. Ultimately, it is your doctor’s obligation to review and make any corrections to your record and patient notes. Your doctor is required to review and edit notes to ensure their accuracy and completeness before finalizing. If you have further questions or concerns, please speak with your doctor.

Your Consent

The use of the AI scribe during your visit is completely voluntary. Your doctor will ask you if you agree to the use of the AI scribe during your visit. You are not required to agree to the use of an AI scribe. You can also

change your mind at any time by telling your doctor if you do not want the AI scribe to be used going forward. The quality of care you receive will not be impacted. If you have any questions or concerns, please feel free to discuss them with us.

First name

Last name

Birthday

Year

Month

Day

I understand and agree to the use of AI-assisted medical note-taking.