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Sign up here to receive email communications from our clinic.

If you would like to receive emails from us please review the information below, complete the form, and submit your information using the button near the bottom of the page. At this time, we will use email only to send you information. You will not be able to reply to email messages that we send.

Your Information

Please enter your first name here.
Please enter your last name here.
Please enter your OHIP or RAMQ number here.
Please enter the email address that you would like us to use to communicate with you.
Please retype your email address to verify it.

MAFHT Patient Consent and Release for Email Communication

We currently, or eventually will, offer email communication with our office for the following:
  • Providing you with appointment details and reminders
  • Inviting you to a virtual appointment
  • Informing you of routine test results
  • Sending you our policies
  • Sending you information about our programs, events and resources
  • Reminding you of tests that are due
  • Sending you forms for tests (labs, x-ray, ultrasound etc.)
  • Asking you to complete Patient Experience Surveys
  • Verifying your contact information
  • Asking you for health card information
  • Asking you to complete questionnaires in preparation for an upcoming appointment

At this time, we will use email only to send you information. You will not be able to submit documents or ask us questions via email. If you would like to receive emails from us, please complete the form above.

There are some limits on what and when we can email you, which we will explain here.
  • Email communication is not a substitute for meeting with your health care provider.
  • Please tell us which email address you wish us to use. You must keep this up-to-date and tell us of any changes to your email address.
  • Email should never be used in an emergency. If you have a medical emergency, you should call 9-1-1 or go to your nearest hospital emergency room immediately.
  • Although we have taken steps to ensure that we can securely send you information by email, we cannot receive incoming messages by email. By accepting this consent and release statement, you agree that you will not attempt to send us information by email.
There are some privacy risks in communicating by email:
  • Email may not be secure. While we have implemented security measures to encrypt and protect our outgoing emails, we cannot guarantee the security and confidentiality of any email you receive from us. As the message leaves The Montfort Academic Family Health Team, it is sent across the internet and it could be intercepted and read.
  • We will document in your medical record that a personalized email has been sent to you when we use this method of communicating with you. These therefore become a permanent part of your health record. As part of your record, the content of the emails may be shared within the Montfort Academic Family Health Team or third parties, with your consent or if we are permitted or required by law (including with other health care providers and insurance companies).
  • We will document in your medical record that you have accepted this Patient Consent and Release for Email Communication once you have submitted your consent and release form.
  • Email is easy to forge, easy to forward (sometimes accidentally and to many people) and may exist forever.
  • We strongly recommend you give us a personal email address that only you have access to and read. We recommend that you use an email address and system that is password protected. If you give us a family email address or share your email address with anyone else, you should know that other people may also receive or read emails we send to you. If you use a work email address, your employer may have a right to archive and look at emails sent from their systems. We recommend you avoid using a work email address.
  • The Montfort Academic Family Health Team is not responsible for information loss due to technical failures.
  • The Montfort Academic Family Health Team may choose not to deal with you by email if you are not able to follow our email rules.
Patient Agreement and Liability Release

By clicking the submit button below, I acknowledge and consent that I have read and fully understand this consent and release form; I understand the risks associated with using email with my health care provider and others at the Montfort Academic Family Health Team and I accept those risks; I understand the limits for using email and I agree to follow those limits.

If I am submitting this form on behalf of a minor, I confirm that I am their LEGAL guardian. If I am submitting this form as a Substitute Decision Maker for a patient, I confirm that I am the current ACTIVE and LEGAL Substitute Decision Maker for this individual.

I understand if I no longer wish to communicate with the Montfort Academic Family Health Team by email, I will let the Family Health Team know.

By clicking the submit button below, I agree that the Montfort Academic Family Health Team, (which for this agreement and release of liability includes its affiliated physicians, affiliated Family Health Organization, staff, agents and officers of the Montfort Academic Family Health Team) shall not be responsible for any personal injury including death, or privacy breach outside the control of the Montfort Academic Family Health Team or other damages as a result of my choice to communicate with the Montfort Academic Family Health Team by email; I release and hold harmless the Montfort Academic Family Health Team from any liability relating to communicating with me by email.

If I had any questions about this form, I asked those questions and agree that my questions have been answered. I understand I have the right to have legal advice about digitally signing this form and what it means to me and have either sought that advice or have chosen not to seek such advice.

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