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, nor guarantee you enrolment with a family doctor. 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.

I hereby consent to assessment and treatment at Spring Health (“SHC”) | Get Well Clinic (“GWC”), Get Well Family Health Team ("GWFHT"), along with Dr. Lai and Associates, collectively referred to as the "Clinic". I agree to participate in the medical assessments, and return for any necessary follow-up. I understand that if I do not have a primary care provider and I receive care at Get Well Clinic, then I may be considered attached to Get Well Family Health Team for the time being. 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 the "Clinic", Dr. Lai & 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 the "Clinic" 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, the "Clinic" 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 & research, and health system planning & management. 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 also understand and consent for my information to be shared with Get Well Clinic, Get Well Family Health Organization, Get Well Family Health Team, and other members of an Ontario Health Team such as North York Toronto Health Partners, to coordinate and provide integrated care.
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 the "Clinic" 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 the "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 Family Health Team, and their 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.
Get Well Clinic works closely with the Get Well Family Health Organization of physicians to find family doctors willing to accept patients. If and when a doctor is available, we need your consent to allow us to enroll you with a family doctor, when available.
ONTARIO: Ministry of Health and Long-Term Care
Patient Enrolment and Consent to Release Personal Health Information
Patient Commitment:
I agree to contact my family doctor, I agree to contact my family doctor, (or if applicable the group to which my family doctor belongs or the designated Telephone Health Advisory Service if available to me), when I, or my enrolled child(ren) or dependent adult(s), need primary care medical advice or treatment. I promise to do this unless there is an emergency of I am travelling away from home. I agree that if I or the person(s) I have signed for move, I will contact my family doctor's office or the ministry (see the box below) with a new address, telephone number, and email. I understand that I can end my enrolment with this family doctor an enrol with another family doctor after six weeks have passed from the date that I complete and sign this form (immediately if I have moved). However, I agree not to change the doctor with whome I am enrolled more than twice a year. I understand that by enrolling a child under 16 or a dependent adult, my signature on the front of this form (or by submitting this form digitally online) means that I agree to these terms and conditions on behalf of that person. When an enrolled child reaches 16 years of age, the ministry will contact him or her to confirm enrolment/consent with the family doctor. I understand and agree that by submitting this form digitally online, I declare I am the person who completed this form and that my digital signature (typed name, datestamp and/or IP address) serves as equivalent to my hand signature.
Consent to Release Personal Health Information:
I understand that my family doctor will be able to offer better medical care if I permit my family doctor and the ministry to share appropriate and relevant information relating to my health. I agree to allow my family doctor, other family doctors in the Patient Enrolment Model (if applicable) and the ministry to exchange the information in this form related to my enrolment. I agree that my family doctor and the ministry can exchange information about my name, address and telephone number.
I agree to allow the ministry to release the following specific information to my family doctor:
- dates of immunizations (flu shots, etc.)
- dates of preventative care screening services (pap tests, mammograms, etc.)
- dates of service, fees paid and fee codes of primary health care services provided to me by a family doctor outside my family doctor's Patient Enrolment Model (if applicable).
If the Telephone Health Advisory Service is available to me, I agree to allow my family doctor and the ministry to exchange only the following information with the designated Telephone Health Advisory Service: my name, health number and version code, address, date of birth, gender.
I understand that this consent to release personal health information ends when :
- My enrolment with my family doctor ends or
- I cancel my consent by writing or telephoning the Ministry of Health and Long-Term Care (see box below).
The ministry will inform my family doctor when the consent is no longer valid. However, I understand that the information already release to my family doctor will remain in my medical file.
Cancellations Conditions
Enrolment with my family doctor and my consent to release personal health information will end when:
a) I cancel my enrolment by writing my family doctor (regular lettermail) or by writing or telephoning the ministry (see box below);
b) I no longer quality for health care services under the Health Insurance Act (Ontario);
c) the Patient Enrolment Modem to which my doctor belongs no longer exists;
d) my family doctor chooses to discontinue acting as my family doctor in accordance with the College of Physicians and Surgeons of Ontario guidelines;
e) I enrol with another family doctor; or
f) the ministry grants me an extended absence.
My consent to release personal health information and/or my enrolment with my family doctor may end when:
a) I consistently fail to meet the obligations to which I agreed in the Patient Commitment (above);
b) my family doctor leaves this Patient Enrolment Model;
c) I become a resident of a long-term care facility;
d) I am imprisoned in a provincial or federal correctional institution; or
e) I move outside the geographic area where the Patient Enrolment Model to which my family doctor belongs regularly provides services.
Show Consent Form
By signing below and/or submitting this form, you agree to the above Consent to Assessment, Treatment & Release Form, and the Governing Law & Jurisdiction Agreement .
(Please sign on the Signature Pad on-screen with your finger or mouse)