Online Volunteer Application Form - Grey Bruce Health Services
I understand that Maple provides the telemedicine technology and will collect my personal health information, as an electronic services provider, and only as required for the purpose of providing me with virtual health care services.
The information sharing consent provided by agreeing to this form includes the sharing of my consultation summary, associated medical records and information related to any consultation I have with an Authorized GBHS Physician for Healthcare Services and their administrative team (e.g., hospital unit clerk or administrative staff) through the Maple Platform. The consultation summary may include a diagnosis, treatment or advice based on my Maple consultation, as well as additional documentation such as specialist referral orders or lab work order information. All consultation summaries are to be held in complete confidentiality and are not to be released to any party apart from GBHS.
Both email and virtual urgent care visits have some inherent privacy and security risks that include your personal health information possibly being intercepted or unintentionally disclosed. By providing us with your email address, you give GBHS consent to send your virtual urgent care visit request confirmation to your email address.
To improve your privacy, and avoid the possibility of others being able to access your personal health information:
By clicking “I Agree” I understand and consent to the above.
If you have any questions or concerns about how your personal health information is being collected or used, please contact Shelly-Ann Rampersad, Vice President of Clinical Operations, Maple, firstname.lastname@example.org.