Medical Release
Start your secure virtual checkup with Refua. This intake collects only what’s needed to coordinate your appointment and request your prior records under Ontario privacy law. All information is encrypted and stored in Canada.
Government-issued photo ID (for verification)
Previous doctor/clinic details (name; address/phone if known)
Full name
Date of birth (YYYY-MM-DD)
Email address
Phone number
Province of residence: Ontario
Preferred language: English
Previous doctor/clinic name
Clinic address (if known)
Phone/fax number (if known)
Authorization to Release Medical Records
I authorize Refua and its assigned licensed clinicians to securely obtain, review, and use my medical records from my previous healthcare provider(s) for the purpose of conducting a private virtual medical checkup. I understand this authorization complies with the Personal Health Information Protection Act (PHIPA) and that my data will be handled per Refua’s Privacy Policy. This release is valid for one (1) year from today unless I revoke it in writing.
• Electronic signature (type full name)
• Date of authorization
By signing, you consent to secure retrieval and storage of your health records in Canada
Upload one valid government photo ID: Driver’s licence, passport or Ontario photo card
After submission, you’ll see live clinician availability via our secure scheduling API. Choose a date and time for your encrypted video session with an Ontario-licensed GP or NP.
Insurance provider (optional)
Current medications/conditions
Notes or special requests
You’ll receive a confirmation email with your signed authorization and appointment details. A coordinator may contact you to confirm your video setup and ID before the session. Need help? 844 875 9955
