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Lorak Medical Assessments
21 Sherman Avenue North · Hamilton · ON · L8L 6L7
Tel: 905.575.8487 · Fax: 905.575.5674
info@lorak.ca · www.lorak.ca

CONSENT FORM

TELEMEDICINE/VIRTUAL ASSESSMENT

You have been asked to attend for an Independent Medical Evaluation (IME) at the request of your employer or Insurance Company.

Claimant Name:    

Policy Number:    

Date & Time of Examination:    

Name of Assessor:    

  1. I understand that my consultation with clinicians will be as a Virtual Assessment. This means that the provider that I see will not be in the same physical location as me.
  2. I understand that I will receive information at the beginning of the session outlining the provider that I am seeing, relevant information about that provider and the location that the provider is working from (city only).
  3. I understand that by using the telemedicine service, I am not establishing an ongoing providerpatient relationship and there will be no follow up.
  4. I understand that LORAK will conform to all privacy and security policies relevant to the provision of this telemedicine encounter.
  5. I understand that this Virtual Assessment is not being recorded, nor will I record this assessment.

Copy(ies) of the report generated as a result of this Virtual Assessment will be released to the referring party.

Your participation in this Virtual Assessment is entirely voluntary and may be terminated at your request at any point during the process. By signing/typing your name or verbally agreeing you indicate that you have been provided with information, such that you are able to make an informed decision and provide written/verbal consent to participate in this Virtual Assessment and further, to release the report to the referring party.

Signature/Name of Claimant:   Date:  
Signature/Name of Witness:   Date:  

A photograph of a drivers licence or health card may be uploaded using the add documents button.

  
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