LIFE Beyond Cancer: Living Well After Treatment – Registration

LIFE Beyond Cancer: Living Well After Treatment - Sign Up

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Have you previously registered as a patient at InspireHealth?*

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New Patient Registration

Yes, I would like to register as a patient or support person with InspireHealth to access free supportive cancer care programs and services.

Name*

First Last

Phone*

Mobile

Email*

Address*

Street Address Address Line 2 City Province Postal Code

Personal Health Number

What is your gender?*

Cancer Diagnosis*

Date of Birth*

Emergency Contact Information:*

Full Name Relationship

Phone*

How Did You Hear About Us?

Please specify who: BC Cancer Agency (BCCA), Canadian Cancer Society (CCS), doctor/physician, healthcare professional, friend, family member, colleague, or other

If you would like to attend an InspireHealth Orientation Session to learn more about our programs and services, please select below which session you would like to sign up for:

Monday, 3:00 – 3:30 pm

Thursday, 5:00 – 5:30 pm

Friday, 11:00 – 11:30 am

I would like to receive reminders about upcoming programs and classes.

I would like to receive reminders about upcoming programs and classes.

InspireHealth Patient Liability Waiver*

Assumption of Risk, Release of Liability, Waiver of Claims, and Indemnity Agreement

ASSUMPTION OF RISKS
I have voluntarily chosen to participate in classes, programs, services, and/or consultations with InspireHealth Society (“InspireHealth”) medical doctors, clinical counsellors, dietitians, exercise therapists and/or other InspireHealth team members or practitioners (the “Services”). The Services may be provided remotely and/or may be provided at an InspireHealth location in Vancouver, Victoria, Kelowna or elsewhere (the “Facilities”).

1. I am aware and understand that there are risks when I participate in the Services and/or use InspireHealth Facilities. Some risks can be anticipated and some cannot.
2. The risks of participating in the Services and of using InspireHealth Facilities include, but are not limited to risks of physical injury, examples of which include: shortness of breath, dizziness, exacerbation of symptoms of my cancer or cancer treatment, increased risk of slips, trips or falls, pain of unknown origin, strains, sprains, overexertion, dehydration, fatigue, aggravation of pre-existing conditions, headaches, tingling or other unusual physical sensations, weakness, nausea, serious injury, permanent or temporary disability, death; risk of adverse psychological effects or of psychological injury, examples of which include: anxiety, depression, irritability, nervousness, trouble sleeping, thoughts of self-harm; property damage; and social or economic losses.
3. Even if InspireHealth has assessed me and provided clearance for me to participate in the Services, this does not eliminate the risks.
4. I am aware of the contagious nature of bacterial and viral diseases including the 2019 novel coronavirus disease (COVID-19) (the "Disease") and that despite any efforts by InspireHealth to reduce the risk of exposure, I may be exposed to or contract the Disease by participating in the Services, by attending InspireHealth Facilities and/or by interacting with InspireHealth staff, contractors and/or members, and that the Disease may result in serious illness, physical injury, disability, death, expenses or other losses.
5. I understand, acknowledge and accept that negligent acts, omissions, advice, or a negligent failure to warn, protect or advise me on the part of InspireHealth and/or its officers, directors, employees, contractors, consultants, volunteers, agents, instructors, therapists, insurers, sponsors, donors, representatives, members, successors, assigns may cause or increase the risk that I will suffer physical injury, psychological injury, property damage, and social or economic loss.

I UNDERSTAND, ACKNOWLEDGE AND AGREE THAT I AM VOLUNTARILY PARTICIPATING IN THE SERVICES and/or ATTENDING THE FACILITIES, KNOWING THAT THERE ARE RISKS TO DOING SO. I AGREE TO ACCEPT AND ASSUME ALL RISKS OF PHYSICAL INJURY, PSYCHOLOGICAL INJURY, PROPERTY DAMAGE, SOCIAL AND ECONOMIC LOSS, DISABILITY, DEATH, AND ANY OTHER LOSS OF ANY KIND WHATSOEVER ARISING FROM OR IN ANY WAY CONNECTED WITH THE SERVICES, MY PARTICIPATION IN THE SERVICES AND/OR MY ATTENDANCE AND USE OF THE FACILITIES, INCLUDING THOSE CAUSED OR CONTRIBUTED TO BY THE NEGLIGENCE OF INSPIREHEALTH OR OTHERS FOR WHOM OR FOR WHICH INSPIREHEALTH IS RESPONSIBLE AT LAW.

RELEASE OF LIABILITY and WAIVER OF CLAIMS
As a precondition to participating in the Services, and as consideration for the value that I will receive by participating in the Services, I agree to all the terms and conditions in this Assumption of Risk, Release of Liability, Waiver of Claims, and Indemnity Agreement (“Agreement”).

I EXPRESSLY WAIVE ANY AND ALL CLAIMS which I have or which I may, in future, have against InspireHealth and/or its officers, directors, employees, contractors, consultants, volunteers, agents, instructors, therapists, insurers, sponsors, donors, representatives, members, successors, assigns and/or anyone who or which might claim contribution or indemnity from any one of them (collectively, the “Releasees”) DUE TO ANY CAUSE WHATSOEVER AND HOWSOEVER ARISING, including on account of any PHYSICAL INJURY, PSYCHOLOGICAL INJURY, PROPERTY DAMAGE, SOCIAL AND ECONOMIC LOSS, DISABILITY and/or, DEATH, examples of which are referred to above in the “Assumption of Risks” section of this Agreement, and including those arising from, or in any way connected to the Services, my participation in the Services, and/or my attendance at and/or use of InspireHealth Facilities.
For greater certainty, I expressly waive my right to seek compensation from any of the RELEASEES FOR ANY REASON WHATSOVER, including but not limited physical injury, psychological injury, property damage, social or economic loss, death and/or disability caused by negligent acts, omissions, advice, or a negligent failure to warn, protect or advise me by any of the RELEASEES, including any breach of any duty of care owed to me pursuant to the Occupiers Liability Act, R.S.B.C. 1996, c. 303, as amended.
I covenant not to make or bring any such claims against InspireHealth or any of the Releasees, and forever release and discharge InspireHealth and the other Releasees from liability under such claims.

INDEMNITY
I AGREE TO HOLD HARMLESS AND INDEMNIFY InspireHealth and the other RELEASEES from and against any injury, loss, damage, expense. liabilities, deficiencies, claims, actions, judgments, settlements, interest, awards, penalties and fines OF ANY KIND WHATSOEVER and arising from or in any way connected with my membership with InspireHealth, my participation in the Services, and/or my attendance at or use of the Facilities, INCLUDING ALL RISKS AND CAUSES REFERENCED IN THE ASSUMPTION OF RISK AND RELEASE OF LIABILITY AND WAIVER OF CLAIMS sections of this Agreement, above.

ADDITIONAL TERMS
I further acknowledge and agree that:
1. Entire Agreement: This Agreement is the entire agreement between me and InspireHealth governing my participation in the Services and use of the Facilities.
2. Severability: If any term or provision of this Agreement is invalid or unenforceable for any reason, it shall be severed and not affect the validity and enforceability of the remaining terms or provisions.
3. Binding Agreement: This Agreement is binding on and shall benefit me, InspireHealth, the other Releasees and our respective heirs, executors, administrators, successors and assigns.
4. Governing Law: All matters arising out of or relating to this Agreement shall be governed by and construed in accordance with the laws of the Province of British Columbia and the federal laws of Canada applicable within that Province. Any claim or cause of action arising under this Agreement may be brought only in the courts of the Province of British Columbia, and I hereby consent to the exclusive jurisdiction of such courts.

I acknowledge and agree that by signing this Agreement, I HAVE READ AND UNDERSTOOD ALL OF THE TERMS OF THIS AGREEMENT AND THAT I AM VOLUNTARILY GIVING UP SUBSTANTIAL LEGAL RIGHTS (on my behalf and on behalf of my heirs, executors, administrators, and next-of-kin), INCLUDING THE RIGHT TO SUE INSPIREHEALTH AND THE OTHER RELEASEES FOR ANY REASON WHATSOEVER.

I am 19 years of age or older and not under a legal disability.

I agree to the Terms of Service

Thank you for signing up as a new patient.

To start signing up for the LIFE program, please check this box.

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Current Patient Sign up

For many people, the transition after cancer treatment is integral to their healing and recovering. There are often questions and uncertainties about how to move forward and adapt to the change that has occurred. This program is intended to support people in this phase of transition after active treatment.

The screening questions below will help determine if this program is a fit for you. If you are unable/unwilling to check any of the boxes below, this program may not be a fit for you at this time. If you would like more information or to discuss further, please contact us by phone or email at info@inspirehealth.ca.

*This program will be offered online via Zoom. Participation will require stable internet and a device with access to video and audio. A cellphone is not recommended for group programming due to limited screen space for engaging with the larger group.

Name*

First Last

Phone*

Email*

Date of Birth*

Emergency Contact*

Full Name Relationship

Phone*

Cancer Diagnosis*

Are you currently receiving cancer treatment?*

Yes

Please specify:

* Please note that treatment can look different for each person, some examples of treatment might look like: surgery, chemotherapy, radiation, or other complimentary or alternative treatments.

Question 1

1. In this program, we will be making space for discussion and personal sharing. To protect the privacy of all participants, we request that each person join from a private space where the videos and voices of other participants will not be seen by others in the household.

By checking this box, you agree with the following statement: I have a computer or tablet with video and audio capability and a private space to participate from.

Question 2

2. This program is designed for people who have had a cancer diagnosis. This program is not for support people.

By checking this box, you agree with the following statement: I have or had a cancer diagnosis and consider myself to be in the transition period after active treatment.

Question 3

3. As the group is intended to create connection between participants and offer a group experience similar to being in person, we request that videos remain on as much as possible.

By checking this box you agree with the following statement: I am willing to participate in small groups and keep my video on as much as possible.

Question 4

4. This program is offered weekly for four weeks. For you to get the most out of the program we ask that you commit to all 4 weeks. We understand that life happens and you may have to cancel a session, but ask you to make your best effort to attend all 4.

By checking this box you agree with the following statement: I commit to attending all 4 sessions.

Do you have any questions?

What is your hope for taking this program?

Is there anything else we should know?

CONSENT TO PARTICIPATE IN TELEMEDICINE CONSULTATION*

Consent to group services and telemedicine:

Confidentiality:

InspireHealth’s multidisciplinary team works as one unit of confidentiality and care, ensuring that any collaboration and communication is done with the utmost respect and ethical consideration. Confidentiality is an essential part of InspireHealth’s practice. Your privacy is important to us. Your healthcare information belongs to you and is held in confidence by InspireHealth, with the exception of the following circumstances:
1. If the information is required by law to be disclosed (e.g., a child or vulnerable person may need protection, the information is subpoenaed, or court ordered to be released).
2. If staff believe there may be a significant risk of harm to you or to others.
3. When informed and voluntary consent is provided by you to release information.

Patient records: Attendance will be tracked and documented in a secure electronic medical records system, which is encrypted and only accessible by InspireHealth clinical staff. Email communication will be used for program communication and coordination, please note that email content may become part of your InspireHealth chart.

Telemedicine: InspireHealth offers the option to access individual and group services through telemedicine, which is the use of telephone and/or video conference platforms. Participation in telemedicine is completely voluntary. At any point, you can choose not to access telemedicine services and speak with an InspireHealth staff member about alternative options for receiving support. If you choose to utilize telemedicine services, InspireHealth will not take video and/or audio recordings of the session. Video calls will be hosted through TELUS Business Connect and Zoom, which are both PIPEDA and PHIPA compliant. For TELUS Business Connect’s privacy policy visit: www.telus.com/privacy. For Zoom's privacy policy visit: https://zoom.us/privacy/. When participating in individual or group services through telemedicine, InspireHealth clinicians assure they connect from a secure and private setting. Confidentiality may be limited on the end of the participant(s). It is each participant’s responsibility to assure they are in a private and secure setting. As InspireHealth cannot assure the environment of participants, we cannot take responsibility for confidentiality being upheld by participant(s).

I acknowledge that I have read and understand the provisions in this form and consent to participate in InspireHealth group services through telemedicine.

I would like to receive reminders about upcoming programs and classes.

By checking this box you understand that we will be in touch with you shortly. You will receive a confirmation and next steps via email. Please make sure to check your junk/spam folder and add noreply@inspirehealth.ca to your safe sender's list.

* Please note that registering for the program does NOT guarantee you a spot. There are limited spaces and we will contact you to confirm registration and waitlist.

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New Patient LIFE registration

Are you currently receiving cancer treatment?*

Yes

Please specify:*

* Please note that treatment can look different for each person, some examples of treatment might look like: surgery, chemotherapy, radiation, or other complimentary or alternative treatments.

Question 1

By checking this box, you agree with the following statement: I have a computer or tablet with video and audio capability and a private space to participate from.

Question 2

2. This program is designed for people who have had a cancer diagnosis. This program is not for support people.

By checking this box, you agree with the following statement: I have or had a cancer diagnosis and consider myself to be in the transition period after active treatment.

Question 3

3. As the group is intended to create connection between participants and offer a group experience similar to being in person, we request that videos remain on as much as possible.

By checking this box you agree with the following statement: I am willing to participate in small groups and keep my video on as much as possible.

Question 4

By checking this box you agree with the following statement: I commit to attending all 4 sessions.

Do you have any questions?

What is your hope for taking this program?

Is there anything else we should know?

* Please note that registering for the program does NOT guarantee you a spot. There are limited spaces and we will contact you to confirm registration and waitlist.