Release of Liability, Waiver of all Possible Claims and Assumption of Risk
**Please review before signing**
INFORMED CONSENT
BOOKING: Upon booking your appointment you will be ask your name, phone number and Health Card number if we need to verify your eligibility for OHIP coverage. Your contact information may be used subsequently to book recall appointments or provide information concerning referrals.
PRE TEST: To facilitate the eye exam process, the staff may conduct a preliminary examination and that information will be provided to Dr Lower, Dr Castro, and/or Dr Barrios ("The Doctor").
EYE EXAM: The Doctor will perform a complete eye exam which includes asking about your previous medical history, family history, medications, symptoms, measurements for the determination of your prescription and exam of the eye for a complete eye check up. If necessary and upon your consent, you will be referred for further tests with an ophthalmologist.
DILATION/DROPS: dilation is an important part of a complete eye exam and involves the use of a medication that will make your vision blurred and sensitive to light for hours, usually for 2 hours. It is necessary for a comprehensive exam of the back of your eyes, and highly recommended in every new case, for diabetic patients, if you have high myopia, if you are over 50 years old, if you are experiencing flashes and or floaters and other situations. It’s not possible to precisely predict how much it will affect your vision so you should make arrangements to not drive or perform hazardous procedures during this time. There is a risk of adverse reactions including allergic reactions and acute glaucoma. This risk varies for each person and The Doctor can discuss that with you so you can decide if you agree to have you eyes dilated.
PRESCRIPTION: The doctor will provide you with a prescription if it’s indicated in your case.
FORMS: The Doctor will charge an additional fee to fill any forms that you need aside from the standard eye examination and prescription.
By signing below, you consent to the above and to the collection of this information that will be used to allow The Doctor to provide the best care for you. The Doctor is committed to collect, use and disclose your information only to the extent necessary for the optometric services and products that we provide. The Doctor may communicate this information to other specialists, health practitioners, technicians or individuals authorized to work in our practice as part of your care. The Doctor may rarely collect information without the patient’s implied consent in an emergency, or if the patient can’t communicate, or where we believe the patient would consent if asked and it’s impractical to obtain consent (e.g. a family member passing a message on from the patient where we have no reason to believe that the message is not genuine)
COVID-19
I hereby acknowledge that I have agreed to meet with The Doctor for the purpose of receiving
Eye Exam.
I acknowledge and accept that there is a risk that I could be exposed to COVID-19 while attending at the Facility. I also acknowledge and accept that while receiving services, the health care provider (HCP) may need to be closer than the recommended social distancing guidelines in order to assess and/or treat me. I acknowledge and confirm that I am willing to accept this risk as a condition of attending at the Facility to receive services from the HCP.
In consideration of the HCP agreeing to see me in person at the Facility, I agree to release the HCP and the Facility (if applicable), their officers, directors, employees, agents and volunteers (the “Releasees”) from any and all causes of action, claims, demands, requests, damages or any recourse whatsoever in respect of any personal injuries or other damages which may occur or arise as a result of exposure to COVID-19 during my visit to the Facility and/or through the provision of services to me by the HCP.
I do hereby acknowledge and agree that notwithstanding the generality of the foregoing, I declare that I will not commence litigation or otherwise seek to recover damages or other compensation against the Releasees based on any action, claim, demand, request, loss or any recourse whatsoever arising from any potential or actual exposure to COVID-19 while attending at the Facility and/or through the provision of services to me by the HCP. I further acknowledge that the Releasees can rely on this Release of Liability, Waiver of all Possible Claims and Assumption of Risk as a complete defence to any and all claims, damages, causes of action, or recourse or liability that may arise at any time.
I have carefully reviewed this Release of Liability, Waiver of all Possible Claims and Assumption of Risk and acknowledge that I fully understand the terms as set out above. I acknowledge that I am signing this Release of Liability, Waiver of all Possible Claims and Assumption of Risk voluntarily.
