Please provide your contact information and review the tele-optometry information provided below. Once complete, you will be directed to a second form where you can provide information regarding your current ocular concern.Which one of our eye doctors do you normally see at our clinic?* Dr. Joe Traynor Dr. Robert Dors Dr. Andrea Traynor Dr. Nikki Huggins Unsure Which office do you normally have your appointment with us in?* Owen Sound Thornbury Your Name* First Last Your Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your Email* e.g. email@example.comYour Phone Number*e.g 1234567899Above number is a* Cell Home Work Tele-Optometry Patient Information* I have read and understand the Tele-Optometry Patient Information (below)“Tele-Optometry” refers to the use of video or audio technology communications by an optometrist to provide optometry services remotely. The Tele-Optometry services (the “Tele-Optometry Services”) with Dr. Robert Dors and Dr. Joseph Traynor, Optometrists (the “Optometrist”), are provided expressly subject to the terms and conditions set out in this Information Sheet. Tele-Optometry Services 1. Tele-Optometry may not be appropriate for every patient. Before proceeding with the Tele-Optometry Services, the Optometrist will consider your health care status and specific optometric needs and will assess the potential risks and benefits in order to determine whether Tele-Optometry is appropriate for you in the circumstances. The Optometrist has sole discretion to determine whether to proceed with the Tele-Optometry Services. 2. While Tele-Optometry provides convenient access to optometry services, Optometrist assessments are more accurate in person with a physical examination. 3. In providing the Tele-Optometry Services, the Optometrist will be relying on the accuracy and completeness of personal health information you provide. The Optometrist is not responsible to determine the accuracy of any information you provide when receiving the Tele-Optometry Services. 4. The Tele-Optometry Services may be subject to restrictions in accordance with applicable laws and College of Optometrists of Ontario policies and standards. 5. Currently, Tele-Optometry Services are not insured services under the Ontario Health Insurance Plan and you will be responsible for charged fees for any Tele-Optometry Services. The Optometrist will advise you of the fees for the Tele-Optometry Services and you will be charged prior to the commencement of the Tele-Optometry Services. 6. Where Tele-Optometry Services are provided to an individual under the age of 18 (a “Child”), consent may need to be obtained from the Child if the Optometrist determines the Child is capable to make his/her own treatment decisions. Otherwise the provision of Tele-Optometry services can be approved by the Child’s parent/guardian. Tele-Optometry Technology 7. The Tele-Optometry Services will be made available through electronic means and third party platforms as determined by the Optometrist (the “Tele-Optometry Technology”). You will require access to the identified Tele-Optometry Technology in order to receive the Tele-Optometry Services. 8. The Tele-Optometry Technology is provided by a third party. The Optometrist has no responsibility for the function and operation of the Tele-Optometry Technology. 9. The Optometrist assumes no responsibility or liability for technical failures or technological issues associated with software, hardware, or internet service providers. Privacy and Security of Personal Health Information 10. Tele-Optometry may involve the communication of sensitive information, including personal health information (such as medical history and conditions, symptoms, examinations and diagnoses), electronically and occurs in real time. The use of Tele-Optometry may increase the risk of your personal health information being unintentionally disclosed or intercepted by third parties. 11. Reasonable efforts will be made to protect the privacy and security of your personal health information, but it is not possible to completely secure electronic information, including information shared by you when receiving the Tele-Optometry Services. The Optometrist cannot guarantee the security and confidentiality of the Tele-Optometry Services. 12. Personal health information is subject to privacy legislation and may be used or disclosed by the Optometrist as permitted or required by law. Patient Responsibilities 13. In consenting to receive Tele-Optometry Services, you must: (a) provide accurate and complete information to the Optometrist in the course of the Tele-Optometry Services; (b) identify yourself with government-issued photo ID upon request of the Optometrist; (c) take precautions to preserve the confidentiality of all electronic communications with the Optometrist; and (d) not make any audio or video recordings of the Tele-Optometry Services without the consent of the Optometrist. Payment* I understand Tele-Optometry is not currently an insured service under OHIP and I agree to pay the fee for this service.Tele-Optometry fee $50 Payment can be made by credit card or e-transferNameThis field is for validation purposes and should be left unchanged.