Consent Form

Patient Information

Pharmacy Name: City Phramacy
Pharmacy Address: 238 Danforth Avenue Toronto, Ontario M4K 1N4
Contact Information: P: 416.469.1898 F: 416.469.5464 E: info@citypharmacy.ca

Introduction

At City Pharmacy, we are committed to providing you with the highest care and service. To do so effectively, we require your consent to collect, use, and disclose your personal and health information for specific purposes related to your treatment and care. This form explains how your information will be used and protected.

Consent to Collect, Use, and Disclose Personal and Health Information

I, hereby authorize City Pharmacy and its designated staff to collect, use, and disclose my personal and health information for the following purposes:
To identify me and communicate with me about my health and treatment.
To provide and manage my healthcare and medication needs.
To process payments or insurance claims.
To share information with other healthcare providers or facilities for my treatment and care.
For internal administrative purposes and to ensure quality service.
I understand that my information will be handled per all applicable privacy laws and regulations and that I have the right to access and correct my personal information.

Protection of Your Information

City Pharmacy is committed to protecting the privacy and security of your personal and health information. We have implemented physical, administrative, and technical safeguards to protect your information from unauthorized access, use, disclosure, alteration, or destruction.

Withdrawal of Consent

I understand that I can withdraw my consent anytime by providing written notice to City Pharmacy. I also understand that withdrawing my consent may affect the pharmacy's ability to provide me with certain medications or services.

Acknowledgment  

I have read and understand the above information regarding the collection, use, and disclosure of my personal and health information by City Pharmacy. I have had the opportunity to ask questions and have them answered to my satisfaction.