MyDovetale - Proxy Access for Patients 12-15 Years Old

**This form must be filled out by the patient. Parents/Legal Guardians are NOT authorized to submit this form on behalf of the patient.**

All fields marked with an * are required.

Patient Information

First Name*

Last Name*

Initials

Health Card Number (Numbers Only)*

Home Address*

City*

Province*

Postal Code*

Telephone Number*

Date of Birth (dd/mm/yyyy)*

Patient's Email Address*

Proxy Information (Optional)

A proxy, such as a parent or legal guardian, is someone who may be authorized to have access to your MyDovetale account.
A proxy may or may not be a patient of St. Joseph’s Healthcare Hamilton.
A proxy can be assigned varying levels of access to a patient’s MyDovetale account, and can by revoked at any time.
Designating a proxy is OPTIONAL – this is not a mandatory step in creating a MyDovetale account
On your 16th birthday, your proxy’s access will be revoked. Should you wish to reinstate or designate a proxy, you may still do so.

If you wish to designate a proxy to your account, please complete the following fields.

Clinical Proxy
Your proxy will have full access to all information in your MyDovetale account, including the ability to schedule and message on your behalf.

Read-Only Clinical Proxy
Your proxy will have full access to all information in your MyDovetale account. They will not be able to schedule or send messages on your behalf.

Scheduling and Messaging Proxy
Your proxy will have no access to view any other information in your MyDovetale account, however, they will have the ability to schedule and message on your behalf.

Please select the type of proxy access you wish your proxy to be granted:

Clinical ProxyRead-Only Clinical ProxyScheduling and Messaging Proxy

First Name

Last Name

Initials

Home Address

City

Province

Postal Code

Telephone Number

Date of Birth (dd/mm/yyyy)

Proxy's Email Address

Does your proxy have a personal MyDovetale account?

YesNo

Has your proxy ever been a patient at SJHH?

YesNoUnknown

Proxies that have not had a registered visit at St. Joseph’s Healthcare Hamilton will be required to sign up for MyDovetale in person at a Clinic that is participating in MyDovetale, or in the Health Information Management Department during regular business hours.

Authorization

By completing this form, I acknowledge and attest to the following:

I understand that I am responsible for complying with the Terms and Conditions of MyDovetale.
I understand that my or my designated proxy’s access privileges may be revoked at any time.
Participating in MyDovetale and selecting a proxy is a voluntary decision made freely and without cohesion.
I am aware that all medical information contained in my MyDovetale account is obtained from my SJHH electronic medical record.
All information provided during this process is true and current, to the best of my knowledge.

Applicable for patients designating a Proxy:

I understand that I may revoke proxy authorization in MyDovetale at any time or I may contact the Health Information Management Department for assistance.
I understand that the individual I identified above will be provided proxy access to my MyDovetale account. As such, they may be exposed to my personal health information, MyDovetale messages and scheduling information. Based on the access I grant my proxy, they may act on my behalf.
I understand that if I am 12-15 years old, a proxy will no longer have access to my MyDovetale account as of my 16th birthday. Once I am 16, I may choose to reinstate or designate proxies – as I see fit.
SJHH is not liable for the actions taken by my proxy.

Patient Consent (Type Full Name)*

For additional information about the request process or information about our privacy protection practices, please visit our website at www.stjoes.ca/privacy.

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MyDovetale Access For Patients 12-15 Years Old

Patient Information

Proxy Information (Optional)

Authorization