Informed Consent | EpiphanyClinic BC

Informed Consent Agreement

Welcome to NorthShore ADHD and Addiction Clinic. We're sending you this secure on-line assessment in order to improve and personalize your care.

Dr. Anthony Ocana

MSc, MD, CCFP, ABAM

Privacy
Your privacy and the security of your data is our highest priority, period.
Your information is anonymous because we don't collect your name or email. We block your IP address, remove any identifiers and encrypt your data before it is transmitted or stored. The only thing that links your anonymous information and your email is your PIN. You choose it, and you decide with whom to share it.

There are however some limits to confidentiality. If your answers suggest that you are planning to hurt yourself or someone else, we have to break confidentiality to keep everyone safe.

Security
We are committed to ensuring the security of your information. Our security protocols meet the highest standards set by British Columbia, the US and the EU. The security of your information is optimized by financial-grade encryption, intrusion detection and all-party use tracking.

Our survey tool, Survey Monkey is the industry standard for university-based research. It is the safest, most secure way of collecting health data and having multiple levels of communication on the internet. It's the same platform used by the Canadian Department of Justice.

Accuracy
We are committed to ensuring the accuracy of your information. We invite you to access, contribute to, or correct your information.

End-User License Agreement

We will only transmit and store your de-identified information.
We will only use your information as agreed.
This product is an assessment and monitoring tool. It is not intended to diagnose or treat any health condition.
There is a limit to our liability.
You will not copy or create a competitive product using our intellectual property.

See full Clinic Privacy Policy here.

on-line assessment before your visit in order to improve your care experience.

Dr. Antonio Ocana

MSc, MD, CCFP, ABAM

CEO and Founder

NorthShore ADHD and Addiction Clinic

I understand and accept the privacy policy

I understand and accept the end-use agreement

Informed Consent for Research Studies

Information for Patients

Will you consent to have your anonymized information used for research?

Medical researchers aim to understand why some people become sick and others do not, what happens when people become sick, and how best to care for people who are sick. Obtaining patient information for research purposes is critical to improving the quality of your care and the performance of the health care system.

You can decide whether you want any of your identifiable personal information included in the study outlined below. If you decide to allow your personal information to be used or disclosed internally or to a third party (i.e., the principal investigator) for the study, please sign this consent form.

You are free to withdraw your consent at any time without giving a reason. A decision to withdraw or not to take part will not affect the standard of care you receive. Your wish to remove your patient information will be respected unless your personal information has already been made anonymous and can’t be identified for removal.

By agreeing to allow your information to be part of the study you are giving permission for the principal investigator and his or her institution to collect, use, and disclose your personal information for the purposes of this research study. Any new research purposes will require new written consent from you.

The principal investigator and employing institution will report and publish research findings and conclusions in a manner that will not identify you, and will not include photographs or visual representations contained in your personal records.

The investigator and employing institution will destroy any individual identities associated with the records as soon as the purposes of the research project have been accomplished, and will notify the practice in writing to this effect. Your personal information will be kept confidential and will be safeguarded to ensure no inappropriate uses or disclosures occur.

If you believe your personal information has been inappropriately collected, used, or disclosed without your consent, you may bring the matter to your practice’s privacy officer. If the matter has not been resolved to your satisfaction, you may bring your concern to the College of Physicians and Surgeons of BC, and failing that to the Office of the Information and Privacy Commissioner for BC.

If you have any questions, please contact Dr. Antonio Ocana at info@northshoreadhd.com

Research Subject Rights

Any person asked to take part as a subject in research involving a medical experiment, or any person asked to consent to such participation on behalf of another, is entitled to receive the following list of rights written in a language in which the person is fluent. This list includes the right to:

1. Be informed of the nature and purpose of the experiment.

2. Be given an explanation of the procedures to be followed in the medical experiment, and any drug or device to be utilized.

3. Be given a description of any attendant discomforts and risks reasonably to be expected from the experiment.

4. Be given an explanation of any benefits to the subject reasonably to be expected from the experiment, if applicable.

5. Be given a disclosure of any appropriate alternative procedures, drugs or devices that might be advantageous to the subject, and their relative risks and benefits.

6. Be informed of the avenues of medical treatment, if any, available to the subject after the experiment if complications should arise.

7. Be given an opportunity to ask any questions concerning the experiment or the procedures involved.

8. Be instructed that consent to participate in the medical experiment may be withdrawn at any time and the subject may discontinue participation in the medical experiment without prejudice.

9. Be given a copy of the signed and dated written consent form. California Subject’s Bill of Rights 08/2011

10. Be given the opportunity to decide to consent or not to consent to a medical experiment without the intervention of any element of force, fraud, deceit, duress, coercion, or undue influence on the subject’s decision.