Electronic Communication Informed Consent Form
Blossom Collaborative Birth Program Use of Electronic Communications Informed Consent
I, (the client), confirm that I am aware of the following conditions, risks, and instructions when using electronic communications including email, fax, text or instant messaging, social media, website and videoconferencing, e.g. Skype and FaceTime:
1.Conditions for Using Electronic Communications
a. Use of electronic communications between me and the Blossom Team Members does not replace an in
person prenatal, labour or postpartum visit and will not be used for any emergencies or time-sensitive matters.
b. While every attempt will be made to respond in a timely fashion to my electronic communication, a guarantee of a specific response time by a Blossom Team Member is not possible.
c. If a response is expected and has not been received within a reasonable time, I may need to follow up to
ensure the intended recipient received the communication.
d. For urgent matters, I am advised to page the on call Blossom Health Provider.
e. Electronic communications concerning treatment or diagnosis will likely be transcribed, printed and/or scanned and made part of my medical record. Only authorized individuals such as other health care practitioners that are part of my health care team or staff and billing personnel may have access to these communications.
f. Blossom team members involved in my care may send electronic communications in order to facilitate the coordination of my care. This information will not be sent to third parties including family members without my prior written consent, except as required or authorized by law.
g. Electronic communications will not be used to communicate sensitive medical personal information such as mental health issues, substance abuse, or sexually transmitted disease.
h. Blossom Team Members will use reasonable means to protect the security and confidentiality of information sentsent and received using electronic communications.
i. I am required to inform the Blossom Team Members of any types of information I do not want sent through electronic communications.
2.Risks of Using Electronic Communications
a. Security and confidentiality of electronic communications cannot be guaranteed and despite efforts to protect the privacy and security of all electronic communications, it is not possible to completely secure the
b. Use of electronic communications increases the risk of sensitive information being disclosed to third parties.
c. Online services may inspect and keep electronic communications passing through their system and may have a legal right to do so.
d. Whenever electronic communications occur, there is a risk of introducing malware into a computer system, potentially damaging and disrupting the security settings.
e. Information sent through electronic communications can be forwarded, stored, circulated and changed without knowledge or permission from the client or Blossom Team Members.
f. Back-up copies may still exist on a computer system although the sender and recipient have deleted copies of electronic communications.
g. All forms of electronic communications may be disclosed in a court order or in accordance with a duty to
h. Skype or FaceTime may increase the risk of interception compared to other forms of videoconferencing.
i. There is an increased risk for emails, text messages, and instant messages to be received by unintended and unknown recipients as these forms of electronic communications can more easily be misdirected.
j. It is not feasible to verify the true identity of the sender with email, text messages, and instant messages
compared with handwritten or signed hard copies. It is also not possible to confirm or ensure that only the
recipient is the one reading the message once it has been sent.
3. Instructions for Using Electronic Communications
a. Limit or avoid using someone else’s computer if possible.
b. Inform the Blossom office of any change in email address, cell phone number or other
information necessary to communicate through electronic means.
c. Include a description of the nature and or purpose of the communication such as “prescription
renewal”, and ensure the full name is in the body of the message.
d. Review messages and ensure they are clear and that all relevant information is provided
before sending to the Blossom office.
e. Confirm receipt of a communication from the Blossom office with a reply message or allow
“read receipts” to be sent.
f. Withdraw consent of receiving electronic communications only by email or written
communication to the Blossom Health Provider or Blossom office.
g. If immediate assistance is required and/or the matter is urgent in nature, understand that
paging the on call Blossom Health Provider is the better option.
Client Acknowledgment and Agreement for Using Electronic Communications:
1. I acknowledge that I have read and understand the conditions, risks, and instructions for use of electronic
2. I accept the risks that are associated with using electronic communications as a means to communicate with
the Blossom Team Members. I consent to the conditions and will follow the instructions as outlined.
3. I acknowledge and understand that although encrypted messages are recommended, it is possible that
electronic communications with the Blossom Team Members may not be encrypted.
General Information about Client Records:
1. I understand that all information about myself and my baby will be kept confidential, except as required by law,
and will be afforded the privacy protections of the BC Personal Information Protection Act.
2. I understand that some of the information I provide will be submitted to the Perinatal Services BC (PSBC), a
program of the Provincial Health Services Authority, for inclusion in a provincial perinatal registry. The data
submitted to PSBC will be used to evaluate perinatal outcomes, care processes and resources, ultimately
improving maternal, fetal, and newborn care in British Columbia.
3. I understand the data submitted to PSBC will be kept confidential, except as required by law, and will be
afforded the privacy protections of the BC Freedom of Information and Protection of Privacy Act.
4. I understand that if I have any questions regarding the collection, use and disclosure of my personal
information, I can contact the Registrar at the College of Midwives of BC at firstname.lastname@example.org or (604) 742-2234.