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v-Medico | Virtual and Physical Walk-in Medical Clinic

Consent for Release of PharmaNet Patient Record

    Patient Information

    PATIENT REPRESENTATIVE INFORMATION

    If authorization is given by a person other than the patient, proof of guardianship or appointment as representative must accompany this form.

    WITNESS INFORMATION

    RECIPIENT INFORMATION

    The PharmaNet record of the Patient identified above should be delivered to the Recipient identified here.

    AUTHORIZATION

    I hereby consent to the Ministry of Health releasing my PharmaNet patient record of

    -

    to the recipient named above for the purposes of

    in accordance with the Pharmaceutical Services Act [SBC 2012] c.22, s.23(2)(b).

    Send this form to PharmaNet Profiles Services
    by fax to 250-953-0432 or by mail to PO Box 9652 STN PROV GOVT, Victoria, BC, V8W 9P4

    Personal information on this form is collected, used and disclosed under the authority of, and in accordance with, the British Columbia Pharmaceutical Services Act and Freedom of Information and Protection of Privacy Act. If you have any questions about the collection or use of this information, call Health Insurance BC from Vancouver at 1-604-683-7151 or from elsewhere in B.C. toll free at 1-800-663-7100.This form contains confidential information intended only for PharmaNet Profiles Services. Any other distribution, copying or disclosure is strictly prohibited. If you have received this fax in error, please write “MISDIRECTED” across the front of the form and fax to 1-250-953-0432, then destroy the pages received in error.

      Governing Law and Jurisdiction Agreement

      for physician in private practice

      This agreement("Agreement") is entered into by and between

      and

      (collectively,the "parties")

      Governing Law

      The Parties hereby agree that:

      a) all aspects of the relationship between

      and

      (as well as her/his agents, delegates, employees, and any physicians and other independent healthcare practitioners providing medical or other healthcare and treatment to

      ,or in association with

      including without limitation any medical or other healthcare and treatment provided to

      b) the resolution of any and all disputes arising from or in connection with that relationship, including any
      disputes arising under or in connection with this Agreement,

      shall be governed by and construed in accordance with the laws of the province or territory of

      (other than conflict of laws rules) and the laws of Canada applicable therein.

      Exclusive Jurisdiction

      The Parties hereby acknowledge that the medical or other healthcare and treatment received by

      from

      will be provided in the will be provided in the

      _, and that the Courts of

      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 healthcare and treatment, or from any other aspect of the relationship
      between

      and

      .

      Date:

      Date: