The Physicians of Justik Medical Clinic have offered to communicate through email or text for appointment notifications. Email or text communication will be applicable to appointment notifications only. No sensitive medical information nor identifiable patient data will be transmitted. The use of a DO NOT REPLY mailbox will be used by Justik Medical Clinic ensuring that patients do not attempt to communicate with their Physician through email.


I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of email or text appointment notifications more fully described in the Appendix to this consent form. I understand and accept the risks outlined in the Appendix to this consent form. I consent to the conditions and will follow the instructions outlined in the Appendix.

I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for electronic communications, it is possible that communications with Justik Medical Clinic may not be encrypted.

I agree to receive appointment notifications from the staff of Justik Medical Clinic with a full understanding of the risk. I acknowledge that either I or the Physician may, at any time, withdraw the option of communicating electronically through the Services upon providing written notice. Any questions I had have been answered.

Risks of using electronic communication:

The Physician will use reasonable means to protect the security and confidentiality of information sent via email communication. However, because of the risks outlined below, the Physician cannot guarantee the security and confidentiality of electronic communications:

Despite reasonable efforts to protect the privacy and security of electronic communication, it is not possible to completely secure the information.

Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system.

Electronic communications can introduce malware into a computer system, and potentially damage or disrupt the computer, networks, and security settings.

Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the Physician or the patient.

Even after the sender and recipient have deleted copies of electronic communications, back-up copies may exist on a computer system.

Electronic communications may be disclosed in accordance with a duty to report or a court order.

If email or text is used as an e-communication tool, the following are additional risks:

Emails and texts can easily be misdirected, resulting in increased risk of being received by unintended and unknown recipients.

Emails can be easier to falsify than handwritten or signed hard copies. It is not feasible to verify the true identity of the sender, or to ensure that only the recipient can read the message once it has been sent.

Conditions of using the Services:

The email and text services will be used only for appointment notifications and will not be used for medical matters.

The use of these Services will be limited to administrative purposes.

The Physician is not responsible for information loss due to technical failures associated with your software or internet service provider.

Instructions for communication using the Services:

The patient must:

  • Reasonably limit or avoid using an employer’s or other third party’s computer.
  • Inform the Physician of any changes in the patient’s email address
  • The use of a DO NOT REPLY mailbox will be used by Justik Medical Clinic ensuring that patients do not attempt to communicate with their Physician through email.
  • Take precautions to preserve the confidentiality of electronic communications, such as using screen savers and safeguarding computer passwords.
  • Withdraw consent only by written communication to the Physician.
  • Justik Medical Clinic will only use email or text for appointment notifications. For medical concerns, you must call the Physician’s office or take other measures as appropriate, such as going to the nearest Emergency Department or urgent care clinic, or call Healthlink at 811.