Virtual Communication Consent Form

Hospice Vaughan Consent For Use of Electronic Communication

First and Last Name:*
Address:*
Phone Number:*
E-mail Address:
Preferred Method of Electronic Communication -Hospice Vaughan has offered to communicate using the following means of electronic communication. I am interested in connecting with Hospice Vaughan via [check all that apply}
- E-mail
- Text Messaging (Including Instant Messaging)
- Videoconferencing (Including but not limited to Skype, Zoom, etc...)
- Other
If you selected E-mail or Videoconferencing, please provide your preferred E-Mail for communication
If you selected Text Messaging (Including Instant Messaging) please provide your preferred phone number:
If you selected "Other" please list here:
Client Acknowledgment and Agreement - By agreeing to and verifying my contact information as set out above, I acknowledge that I have read and fully understand the risks, limitations, and conditions for the use of electronic communication as set out. I agree with the instructions for the use of electronic communication, including any additional or other instructions that Hospice Vaughan may add to electronic communications. I acknowledge and understand that encryption software may be used as a security mechanism for electronic communication in selected communications. Although, I understand electronic communications with Hospice Vaughan may not always be encrypted, I consent to electronic communications with Hospice Vaughan and its affiliates (i.e. staff, volunteers, students, third parties, clients and other community members).*
- Agree
- Do NOT Agree
Limitations on the Collection and Disclosure of Personal Information - The following issues or matters are not to be collected or disclosed in my electronic communications:
This consent is valid for 1 year from the date I agreed to electronic communication with Hospice Vaughan. Any questions I had, have been addressed. I understand that Hospice Vaughan or I, may withdraw these options for use of electronic communication at any time by providing written notice.*
- I have read, and understand this agreement.
By selecting "ACCEPT" I am confirming my contact information, as set out in this agreement, and having read the risks, terms and conditions and instructions set out below, I provide my agreement and consent to communicate electronically with Hospice Vaughan.*
- ACCEPT
- Do NOT Accept

CLICK HERE FOR TERMS AND CONDITIONS, PLEASE READ BEFORE CLICKING “SUBMIT”

BY CLICKING “SUBMIT” YOU AGREE AND UNDERSTAND ALL TERMS AND CONDITIONS LISTED IN THE ENCLOSED DOCUMENT ABOVE

FOR YOUR RECORDS: You may download a copy of the Terms and Conditions HERE

Should you require additional information please contact Hospice Vaughan at info@hospicevaughan.com or 905-850-6266

Hospice Vaughan

31 Woodbridge Ave, Vaughan, ON, L4L 7K4

905-850-6266