* To download this form, click here.
Providing the best possible medical care to our patients is our foremost priority. In order to serve all of our patients optimally, we follow a set of clinic policies in compliance of the standard of practice in this province.
We ask that all of our patients respect our policies and we encourage everyone to ask us questions they may have regarding these policies.
* Please read the following Clinic Policy carefully and initial each item. If you have any questions, please let us know before signing.
* As a patient at Mango Medical Clinic, you are entitled to some important Patient Rights. Please visit: www.mangomedical.ca/PatientRights for details.
- I agree to attach to Dr. __________________ as my family doctor and:
- Seek my health care from the Mango Medical Clinic whenever possible.
- Identify my doctor in Mango Medical Clinic as my family doctor when I visit any health care provider.
- Not have another family doctor as a regular doctor.
- Communicate with my doctor honestly and openly.
- Respect Mango Clinic staff and refrain from any form of verbal or physical aggression or harassment.
Consent to Transfer Charts
- I understand that to provide adequate care to me, my doctor needs accurate and complete information of my existing medical files. I hereby give consent to my doctor to request for medical files, chart, and documents from hospitals, clinics, laboratories, and other health care facilities that are necessary for taking care of my medical needs. I will inform the doctor should there be any exceptions to the above.
Clinic appointment bookings:
- A typical visit is scheduled for 10-15 minutes, depending on type of visit.
- Whenever possible, I will inform the clinic of the reason(s) of my visit so that the clinic can budget time appropriately.
- Longer appointment for complete physicals or procedures will be booked at the doctor’s discretion.
- I acknowledge that if I have multiple issues, my doctor will prioritize them in the allotted time and may schedule follow up visits to go through my issues thoroughly.
- My physician may provide limited walk-in service to his own patients for the following indications: medical emergencies which cannot be delayed to the following day; severe infectious symptoms; and urgent recalls requested from the doctor. Prescription refills do not qualify for same day visits. It is my responsibility to ensure the timely refill of my medications.
- I acknowledge that Mango Medical Clinic does NOT provide routine childhood immunizations for children under 6 years old. I need to contact the closest public health unit for these immunizations. This is to reduce the anxiety of the children about coming to see their doctors and to maintain a permanent immunization record at the public health unit.
Opioids, Sedatives and other controlled substances:
- I have read, and agree to the following:
- There is insufficient clinical evidence that long term, escalating doses of opioid treatment is beneficial for chronic, non-cancer pain. Inappropriate use of opioid medications can lead to more harm than good. For the best quality of care, patients at Mango Medical Clinic will adhere to the Opioid Treatment Agreement before starting opioid therapy.
- The College of Physicians and Surgeons of BC has a formal policy statement forbidding the concurrent use of Opioids and Sedative medications, and my doctors are legally obliged to stop one or more of these medications with a taper.
- Some parts of the Opioid Treatment Agreement includes: opioid medications must be prescribed to you by a single physician only. Patients on opioid medications are subject to PharmaNet Checks and Random Drug Screening. Your physician has the right to terminate opioid prescribing for you if any item of the Agreement has been breached.
- Our Opioid Treatment Agreement is available for review here.
- I understand that some services are not covered by the provincial Medical Services Plan. I have the right to know the Mango Clinic service fees before agreeing to the treatment.
- Common uninsured services include:
- If an outstanding account has been incurred by me, payment is expected upon arrival at the next appointment.
- Dependent upon the type of appointment, Mango Medical Clinic may not be able to schedule future appointments until the balance has been paid.
Late or missed appointments:
- As appointments are in high demand, a 24 hours’ notice is required to cancel appointments. This notification allows Mango Medical Clinic to offer available time to other patients needing care.
- If I am late for my appointment and my doctor has to see the next patient, the clinic will try to fit me in at a later time slot. If I am unable to be seen due to my lateness, it is considered a missed appointment.
- Missed appointments are subject to a fee as recommended by Doctors of BC.
Ending the therapeutic relationship:
- A positive therapeutic relationship relies on mutual trust and respect between the patient and the physician. If this foundation is lost, a productive therapeutic relationship may no longer be possible, and either the patient or the physician may choose to terminate this doctor-patient relationship.
- Mango Medical Clinic will provide resources where I may be able to find another physician.
- After ending the therapeutic relationship, I have the right to seek care from the clinic for up to 1 month for emergency reasons.
- If the reason for terminating the care relationship involves verbal or physical aggression towards any clinic staff, the grace period will not apply due to workplace anti-harassment legislation.
- It is within my right to at any time end the therapeutic relationship and transfer my care to another clinic. A chart transfer fee will be applicable.
- I consent to the doctor or an Allied Health Professional (such as a nurse or pharmacist) in the clinic checking my prescription records in BC on my PharmaNet profile where all my recent prescription medications are documented.
Receiving Email Communications
- I consent to receiving clinic notices by email, such as for Flu Clinics, screening test reminders, and clinic updates. I understand and accept that there is a small inherent risk to email communication such as unauthorized access. Emails from Mango Medical Clinic will not contain any medical information such as test results or specialist reports.
- Mango Clinic doctors may provide medical education for residents or medical students in the clinic. My doctor will ask for my consent to see a medical learner before I see them.
- The medical learner will always review my encounter with one of the clinic doctors, and I can also ask to see the clinic doctor after seeing the learner.
- I will always have the choice of declining to see a medical learner, and this will not affect my medical care with the Mango Medical Clinic in any way.