Email Policies and Consent Form

Please review the following email policy and submit consent below.


Risks of using email:

Transmitting patient information poses several risks of which you should be aware.

You should not agree to communicate via email without understanding and accepting these risks.

The risks include, but are not limited to, the following:

  1. Email communications can be forwarded, intercepted, circulated, stored or even changed without the knowledge or permission of Acton Medical and Urgent Care or the patient.  Email senders can easily mis-address an email, resulting in the email being sent to unintended and unknown recipients.

  2. Email communication is easier to falsify than handwritten or signed hard copies.  In addition, it is impossible to verify the true identity of the sender, or to ensure that only the recipient can read the email once it has been sent.

  3. Email communications may be permanent.  Even after the sender and recipient have deleted their copies of the email, back-up copies may exist on a computer or in cyberspace.

  4. Use of email to discuss sensitive information can increase the risk of such information being intercepted by others.

  5. Email can introduce viruses into a computer system, and potentially damage or disrupt the computer, networks, and security settings.

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

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

Conditions of using email:

Acton Medical and Urgent Care will use reasonable means to protect the security and confidentiality of email communications sent and received.  However, because of the risks outlined above, the security and confidentiality of email communication cannot be guaranteed.  Thus, you must consent to the use of email which includes agreement with the following conditions:

  1. The emails are received and reviewed by the office staff. 

  2. Email communications may be added/printed/transcribed to the patient’s medical chart.  

  3. While the office staff will attempt to read and respond promptly to your email (3-5 business days), we cannot guarantee that any particular email will be read and responded to within that period of time.  Thus, email is NOT to be used for medical emergencies or other time-sensitive matters.

  4. If your email requires or invites a response and you have not received a response within (3-5 business days) the it is your responsibility to follow up on this.

  5. Please be aware that when you sign a consent with a third party who is requesting your records, such as insurance companies and lawyers etc.; many third parties are now including a request for email communications, when they are requesting patient records from medical offices.

  6. We may forward your email communications to others parties involved with your medical care and/or any parties that we have received authorization from or if required by law.

  7. Email communication is not an appropriate substitute for clinical assessments. You are responsible for following up on emails and for scheduling appointments when warranted.

  8. Email should not be used for sensitive medical information, such as sexually transmitted disease, AIDS/HIV, mental health, developmental disability, or substance abuse.

  9. This email is for the intended purpose of communications of a medical nature with Acton Medical and Urgent Care Staff.  Do not send emails outside of this nature….jokes, funny pictures etc. or they will be deleted without review.

  10. We are not responsible for information loss due to technical failure.

Instructions for communication by email:

  1. Use your own personal computer or cell phone or electronic device.

  2. Inform Acton Medical and Urgent Care of any changes in your email address.

  3. Complete an updated email consent form when/if you email address changes.  

  4. In the subject line of your email your must include the patient's name as it is written on the health card and the brief reason for the email (e.g., "John Doe - prescription renewal").

  5. Review your email prior to sending it to the office to ensure that your email is clear and that you have provided all relevant information.

  6. Use passwords to secure access to your computer, cell phone and/or electronic device.

  7. If your wish to withdraw your consent for email communication, this needs to done by either emailing the office or submitting a letter stating the following:  date, patient name as it is written on the health card, patient's date of birth and "I am revoking my consent for email communication".  Once received, the office will remove your email address from your chart and block your email address in our incoming emails. 

  8. If you require immediate assistance, or if your condition appears serious or rapidly worsens, do NOT rely on email. Contact the office by phone 519-853-4449.

If after reviewing the above risks, conditions and instructions for Email, you would like to use Email communicate with Acton Medical and Urgent Care; please complete the following:



Thank you for completing the Consent to Email Communications Form