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5 Swan Lake Blvd, Unit 7
Markham, ON L6E 0K7
50 McIntosh Drive, Unit 239
Markham, ON L3R 9T3

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Home » Consent Forms » Eclaim Consent Form

Eclaim Consent Form

 

Electronic transmission authorization and consent form

Provider: Dr. Yilei Wang, Optometrist, Markham Eye and Vision Care

Address: 5 Swan Lake Blvd., Unit 7 Markham ON L6E 0K7; Phone: 905-471-8118; Fax: 905-471-9119

Patient:

Patient Name(Required)
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Consent to collect and exchange personal information

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All information contained herein is protected by privacy laws including the Personal Information Protection and Electronic Documents Act (PIPEDA) and all the corresponding provincial legislation. All users agree to protect the personal health information contained herein from unauthorized use, disclosure, loss, theft, or compromise in accordance with the above noted laws and with at least the same care employed to protect their own confidential information. Any unauthorized access, disclosure or use of this information is illegal.
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