**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.
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.
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.
By completing this form, I acknowledge and attest to the following:
Applicable for patients designating a Proxy:
For additional information about the request process or information about our privacy protection practices, please visit our website at www.stjoes.ca/privacy.