Dear Patient: Please complete this health history questionnaire to the best of your ability. Your Anesthesiologist will review it prior to your Virtual Consultation.
Kemptville District Hospital collects the information you provide in this form under the authority of the Freedom of Information and Protection of Privacy Act, the Personal Health Information Protection Act and the Public Hospitals Act. By completing this form you are consenting to the hospital’s collection of the personal health information you provide on this form. The Hospital cannot guarantee that your electronic completion or submission of this form is secure and confidential. If you choose to complete or submit this form to the Hospital (or both) using electronic mail or the weblink provided or both, each of which may be unsecured, you agree to:
- assume all risks associated with doing so, including a risk of unauthorized collection, use or disclosure of the information contained in this form; and
- waive all claims you or your dependants may have against the hospital arising from your use of electronic mail or the weblink provided or both; and
- release the hospital from any liability or losses accruing to you or your dependants as a result of your use of electronic mail or the weblink provided or both.
You have the option to complete and submit this form by choosing one of the following alternatives:
- You may print a copy of this form, complete it, put it inside an envelope, and mail it to –
Kemptville District Hospital,
Attention Bookings Department,
2675 Concession Road, PO Box 2007,
Kemptville, ON K0G 1J0; or
- You may print a copy of this form, complete, scan it and send it electronically to the hospital at SurgicalBooking@kdh.on.ca. By choosing this option you agree to assume all risks associated with unsecured electronic transmission, waive all claims against the hospital associated with such transmission and release the hospital from all liability or losses accruing to you and your dependants as a result of such transmission; or
- You may participate in a telephone conversation with a hospital representative who will collect the information. Please call (613) 258-6133 extension 281 to schedule a telephone discussion.