It is the responsibility of healthcare providers to ensure their patients are informed and give consent before using Autochart.ai. Transparent communication about how Autochart.ai is used, what data is processed, and the measures in place to protect patient privacy is crucial to maintaining trust and compliance with regulatory requirements.

Share these resources with your patients for added assurance:

Below, we provide a sample consent form that can be copied and customized to suit your clinic's needs.

FOR _________________________________________________ (“Clinic”)

The Clinic would like to use an automated charting application (the “Application”), Autochart.ai, that records the interaction between the health care practitioner (“Practitioner”) and the Patient during examinations (the “Voice Recording”) to enhance efficiency in clinical documentation and help the clinical team address follow up tasks faster.

The Application records only the audio and date, it summarizes the content for your medical record and then deletes the recordings. The summarized transcript is used exclusively for charting purposes.

The Clinic is committed to protecting your privacy with stringent security measures and by retaining only essential data for providing our services. The Application, Autochart.ai, complies with applicable privacy law and the data it collects remains in Canada.

Your participation is entirely voluntary. Your decision not to participate will not affect your access to medical services from the Clinic. You acknowledge that you have the right to withdraw your consent at any time, without any negative impact on your treatment.

INFORMED CONSENT:

I, Patient name (please print):_________________________________________________________ (the “Patient”), confirm that I have read, understood, and I

[ ] Consent that the Clinic may use the Application to capture a voice recording of my interaction with the Practitioner which will be transcribed and used for my medical records.

[ ] Do not consent for the Clinic to capture a voice recording of my interaction with the Practitioner

Patient's Signature: _______________________________ Date: _________________

If the Patient is under the legal age of consent or is unable to provide informed consent, a parent or legal guardian must sign below, indicating such parent or legal guardian’s approval on behalf of the Patient.

Parent/Guardian Name: _____________________________ Relationship: ___________

Parent/Guardian Signature: __________________________ Date: _________________