ENROLLMENT FORM



BASIC INFORMATION
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Sex: *
Do you consent to email communication with DeerFields? *
What method of communication do you prefer? *
Does anyone other than yourself have access to this email? *


HEALTH INFORMATION
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Do you have a Family Doctor? *
Do you currently have a preferred Pharmacy? *


PAYMENT INFORMATION
Payment Method: *
Visa


MEDICAL EXAMS
Please select which Exam you want to complete: *
** Annual Program includes initial assessment plus 3 quarterly reviews
 
*  Payment option includes initial hormone assessment 
    Follow up appointments $395.00 (every 3 months)

RESCHEDULING AND REFUND POLICY 

COMPREHENSIVE HEALTH EVALUATION: Services commence approximately 5 days prior to your in-clinic appointment with the collection of blood for laboratory testing. Appointments should be booked at least ten days before blood collection is scheduled. Rescheduling the blood collection appointment requires your clinic appointment to be rescheduled. Due to the team collaboration required for the CHE, rescheduling requires rescheduling of a number of related specialists services. Clients who need to reschedule blood collection or in-clinic appointments will be subject to a rescheduling fee of $500.00.

NON-OHIP SERVICES

The Client understands that the Programs are wellness programs that are intended to enhance the Client’s well-being and quality of life, but that the Programs are not medically necessary.

No aspects of the Programs or any other service provided by DeerFields Clinic are covered by the Ontario Health Insurance Plan or any other provincial health insurance, or by private health insurance coverage. The cost of such Programs is the responsibility of the Client.

In the course of the Program, the DeerFields Clinic physician may identify a health condition or symptom, the treatment of which is medically necessary, and which treatment, therefore, would be covered by OHIP or other applicable provincial health plans or private health insurance. Where such treatments are medically indicated and are provided to residents of Ontario, the DeerFields Clinic physician will be required to bill OHIP for such treatments. Such treatments are not included in any fees charged by DeerFields Clinic to the Client.

The provision of any Program by a DeerFields Clinic physician to a Client does not make such physician the Client’s primary care physician. The Programs offered at DeerFields Clinic are not replacements for primary health care. The Client acknowledges that his or her participation in any Program may have implications for proper primary health care, particularly, though not exclusively, with respect to drug interactions. The Client agrees to promptly advise his or her primary care physician of his or her relationship with DeerFields Clinic, and acknowledges that a DeerFields Clinic physician is available to discuss the Program with the Client’s primary care physician.

DISCLOSURE

Please note that Dr. Randy Knipping has a financial interest in DeerFields.

MEDICAL AND PERSONAL INFORMATION

The Client acknowledges and consents to the collection and retention of personal information by DeerFields Clinic for the purposes of providing health and wellness services to the Client. DeerFields Clinic will take all appropriate efforts to ensure the ongoing confidentiality of the Client’s information. The Client acknowledges that DeerFields Clinic may share Client personal information with health laboratories for purposes of specimen testing and analysis, and may share Client personal information with allied health care professionals employed or under contract to deliver services to the Client through DeerFields Clinic and with consulting physicians in circumstances where additional physician review may be useful for assessment of testing results and therapeutic recommendations.

The Client consents to such use of personal information.

The Client acknowledges that Client personal information may be used for research purposes, to improve age management medicine testing and treatments, but that in such circumstances the Client’s personal information would be stored and used only in a manner that ensured the Client’s identity is not revealed to any third party and that the Client is not identified or personally identifiable from such data. The Client consents to the retention and usage of personal information.

FAILURE OF PAYMENT

In the event that the undersigned fails to make any payment when due under the DeerFields Clinic and such payment is not made, in full, within thirty (30) calendar days after written notice is received of such failure, DeerFields Clinic shall be entitled, in its sole and absolute discretion, to cancel and terminate the undersigned’s membership and any and all related coverage(s) or treatment(s) under the program, without further notice. As part of this application, and after being accepted, the undersigned acknowledges and agrees that certain information shall be requested and provided, from time to time, concerning his or her personal health, financial and other private matters in connection with the DeerFields Clinic. By signing and delivering this application, the undersigned agrees and consents to DeerFields Clinic or its authorized representatives collecting, using, sharing or otherwise disclosing such personal and private information for the purposes of such program and for no other or improper purpose.

YOUR RIGHTS UNDER THE CONSUMER PROTECTION ACT, 2002

You, the Client, may cancel this agreement at any time during the period that ends ten (10) days after the later of the day you receive a written copy of the agreement and the day all the services are available. You do not need to give the supplier a reason for cancelling during this 10-day period. In addition, there are grounds that allow you to cancel this agreement. You may also have other rights, duties and remedies at law. For more information, you may contact the Ministry of Consumer and Business Services. To cancel this agreement, you must give notice of cancellation to the supplier, at the address set out in the agreement, by any means that allows you to prove the date on which you gave notice. If no address is set out in the agreement, use any address of the supplier that is on record with the Government of Ontario or the Government of Canada or is known by you. If you cancel this agreement, the supplier has fifteen (15) days to refund any payment you have made and return to you all goods delivered under a trade-in arrangement (or refund an amount equal to the trade-in allowance).

PROVISION OF SERVICES

The Client acknowledges that he or she has read and understands this consent and acknowledgement, that they have not been provided, and that they have no expectation of, any guarantees or warranties of results of the Programs or any other services. The Client may also refuse to provide this consent and acknowledgement and decide to not participate in the Program.

All medical services are provided by, and under the direction, care and control of, licensed medical practitioners provided through the facilities of DeerFields Clinic. The Client acknowledges that the Programs and elements of the Programs may not be provided by the same DeerFields Clinic Physician, and that some services may be provided by third parties contracted to DeerFields Clinic, for example, mobile ultrasound services.

In consideration of receiving, and as condition of DeerFields Clinic providing, the Program, the Client, on the Client’s own behalf, and on behalf of the Client’s estate and heirs, hereby releases DeerFields Clinic, its directors, officers, employees and agents from any and all claims or liability for any injuries, losses or damages suffered by the Client and arising from any risks the Client has assumed and consented to pursuant to this agreement.

Client Agreement: *
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DeerFields
DeerFields Clinic 111 The West Mall, Etobicoke, ON, M9C 1C1 Tel 416.253.9769 Fax 416.253.4389
DeerFields Estate 17084 Duffy's Lane, Palgrave, ON, L7E 3C2 Tel 416.253.9769 Fax 416.253.4389
www.deerfields.ca
clinic@deerfields.ca