Vasectomy Form

Femina Medical Clinic - 1265 rue Berri, office 430, Montreal, Quebec H2L 4X4
(hereinafter called the Clinic)

I hereby certify that I have read and fully understood the risks, restrictions, conditions and instructions for use of the chosen Electronic Communication Services (e-mail and text message, hereinafter referred to as Services) and a full description of which can be found at appendix to this consent form. I understand and accept the risks listed in the appendix to this form that are associated with the use of the Services in the context of communications with the Clinic or members of its staff.
I agree to the conditions and will comply with the instructions listed in the appendix, as well as any other measure that the Clinic may impose in relation to communication with persons using the Services. I acknowledge and understand that despite the recommended use of encryption software as a system to secure electronic communications, it is possible that communications with the Clinic or members of its staff using the Services, may not be encrypted. I agree, however, in full knowledge of the risks, to communicate with the Clinic and the members of its staff by means of these Services.

The transmission of your questionnaire will be done by email on behalf of the Clinique médicale Fémina, via the orchestrator of the website managed by SFR.
The collection of information is made in order to optimize your medical appointment.
Only the employees and physicians of the Clinique médicale Fémina will have access to this information.
Required information is marked with an asterisk.
If you do not wish to complete the questionnaire online, it will be possible to complete it on paper at the clinic.

ANNEX :
Risks associated with the use of an electronic means of communication:
• The Clinic will use reasonable means to protect the security and confidentiality of information sent and received through the Services.
• However, due to the risks mentioned below, the Clinic cannot guarantee the security and confidentiality of electronic communications.
• The use of electronic communications to discuss sensitive information may increase the risk of such information being disclosed to third parties.
• Despite reasonable efforts to protect personal information and ensure the security of electronic communications, it is not possible to completely secure this information.
• Employers and online services may have a legal right to inspect and preserve electronic communications received and transmitted by their system.
• Electronic communications may introduce malicious software into a computer system which could damage or disrupt the operation of the computer, computer network or security systems.
• Electronic communications may be rerouted, intercepted, broadcast, stored or even altered without the Clinic or Patient's knowledge or authorization.
• Even if the sender and recipient have deleted the e-mail messages, there may be backup copies on a computer system.
• Electronic communications may be disclosed pursuant to a reporting obligation or court order.

Using email or text messages as a means of electronic communication carries the following additional risks:
◦ Emails and text messages can be easily re-routed, increasing the risk of being unintentionally sent to an unknown recipient.
◦ It is easier to forge an email and a text message than a handwritten or signed document.
◦ Furthermore, it is impossible to verify the identity of the sender or to ensure that only the recipient will be able to read the email once it is sent.

Conditions of use of the Services:
◦ The Clinic is not responsible for the loss of information caused by technical failures related to the patient's software or internet service provider.

Instructions for Communicating Through the Services
The patient who communicates with the Clinic through the Services must:
• Avoid as much as possible using a computer belonging to your employer or a third party.
• Inform the Clinic of any change made to their email address, cell phone number or any information required for the use of the Services.

If the Services include email and text messages, the patient must:
• Proofread all electronic communications before sending them to the Clinic to ensure that messages are clear and contain all relevant information.
• Take the precautions required to respect the confidentiality of electronic communications, such as using a screen saver and protecting passwords.

To prepare yourself for the assessment and counseling consultation that must be done before the vasectomy, we ask you to read certain sections of our website:
In the “Vasectomy” tab read the sections:
- What is vasectomy?
- Before vasectomy
- After vasectomy