Signature


If you are having trouble with the signature pad below, please use alternate form: Registration - Sign by Hand.
Please Sign below, on the screen with your mouse.


If you are unable to see your signature on screen above, then please do NOT proceed any further with this form. Instead, click and complete this alternate form: Registration - Sign by Hand.

If this is your first time attending our clinic, please enter your details for a faster first time check-in.
We use this information to create a new record in our system. Please note that completion of this form does not guarantee you service at our clinic. This just expedites the process.

If you have been to our clinic before and have registered your details with us, you do not need to complete this section, unless your address has changed.

(JPG,GIF,PNG,TIF,PDF only)

I hereby consent to assessment and treatment at Spring Health (“SHC”) | Get Well Clinic (“GWC”) with Dr. Lai and Associates. I agree to participate in the medical assessments, and return for any necessary follow-up.

I understand and agree that the health care practitioners will assess and treat me to the best of their knowledge and abilities, in accordance with their training and qualifications. Due to the nature of medicine as not an exact science, I understand and agree that in rare circumstances, medical errors can occur. I agree to be a full participant in working with my healthcare provider to avoid any errors that may occur. If I am not confident of the care I am receiving, I understand that I am also free to get a second opinion on my own seeking. If I am not satisfied with the care that I receive, I will endeavor to communicate and work with my healthcare provider and staff at GWC to resolve any issues. If I am still not satisfied, I understand and agree that I am not obligated to stay, and that I am free to take my care elsewhere. I will endeavor to be courteous when I communicate with the doctors and office staff, and also when I relay my positive or negative experiences to others regarding the care I received.

I give consent and permission for Dr. Lai and his associates to communicate and exchange my personal and medical information with other members of my healthcare team for the purposes of managing my health. I understand that the electronic medical record at GWC is a common shared system among the associates of the clinic. I understand that only those health care providers who have an active role in treating me are considered part of my circle of care; and that they may have access to my records but limited to what is necessary in order to provide me with the care they are responsible for.

This consent form is NOT an authorization for releasing my medical records to a third party. However, I hereby understand that if I ever authorize my transfer of my medical records to third parties (such as insurance companies, lawyers, or designates), my records with potential sensitive and personal information may be included in the transfer. I understand that I may choose to withhold my records or redact portions of my transferred files, however, there will be a notice to the third party that the records transferred are incomplete. Furthermore, Spring Health Corp, Get Well Clinic, and Dr. Lai and Associates cannot be held responsible for who access the records once the records have left the office in the possession of an authorized individual.

I also give consent and permission to have my health data and information be collected and analyzed for the purposes of education, quality improvement and research. I understand that any data presented in a public form (such as presentations, journals, or publications) will not include my personal identifying information; I shall remain anonymous, unless I give further consent at a later date.
I understand that electronic communication is not a substitute for in-person communication or clinical examinations with a doctor, where appropriate, or for attending the Emergency Department when needed (including for any urgent care that may be required). I give express consent to Spring Health Corp, Get Well Clinic, Get Well Rehab, Dr. Lai and Associates, to communicate with me via electronic communications for purposes including, but not limited to: general advice, specific coaching, receiving reminders, announcements, and promotions for features, products, services, or other allied-health providers relating to my healthcare. I understand that I can unsubscribe from such communications at any time in writing. I understand that any communications through paper, phone, fax, email, text, or video-conferencing has inherent security and privacy risks. I endeavor to engage in safe communication practices. I understand that Get Well Clinic cannot guarantee confidentiality when communicating with insecure methods (such as email). I hereby covenant and agree to release, indemnify, and save harmless Spring Health Corp, Get Well Clinic, Get Well Rehab, Associates and staff for any costs, losses, damages, liabilities, claims, actions, proceedings and all legal and other costs of any action whatsoever, from what may occur as a result of communicating through paper or electronic methods.
Regarding the Governing Law, I hereby agree that: all aspects of the relationship between me and Get Well Clinic (the “Clinic”), as well as Spring Health Corp (the "Corporation"), their agents, delegates, employees, and any physicians and other independent health care practitioners providing medical or other health care and treatment to me at or in association with the Clinic or Corporation, including without limitation any medical or other health care and treatment provided to me, and the resolution of any and all disputes arising from or in connection with that relationship, including any disputes arising under or in connection with the Agreement, shall be governed by and construed in accordance with the laws of the Province of Ontario and the laws of Canada applicable therein. Regarding the Jursidiction: I hereby acknowledge that the medical or other health care and treatment I receive (on-site or remotely) from Get Well Clinic and Spring Health Corporation will be provided in the Province of Ontario, and that the Court of the Province of Ontario shall 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 Get Well Clinic or Spring Health Corp.

If you agree to the Consent to Assessment, Treatment & Release Form, the Governing Law & Jurisdiction Agreement, and have signed your signature at the beginning of this Registration Form, please click SUBMIT.

Powered by ChronoForms - ChronoEngine.com

Shopping cart 购物车

 x 

Cart empty