First Name

Last Name

Email (used for your CareWay account)

Phone

Clinic / Company

Postal Code (practice location)

Province Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nunavut Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon Other

Profession Family Physician Nurse Practitioner Registered Nurses in Remote Communities Pediatricians who Provide Longitudinal Care in the Community

Practice Number

EMR used ACCURO ARYA AVA AVAROS CEREBRUM CERNER CHR CIS EMR ADVANTAGE EPIC GLOBEMED HEALTHQUEST INTRAHEALTH JUNO MAPLE MED ACCESS MEDESYNC MEDITECH MOIS MUSTIMUHW MYLE Ofys OKAKI Omnimed OSCAR PROFESSIONAL PLEXIA PROFILE PS SUITE YES YMS MD Purkinje

I confirm that my professional information is up to date and that I am in good standing with my professional order. I also consent to CareWay sharing this information with Canada Health Infoway to determine my eligibility for the program.

I have read and accept the sections "Consent to Data Sharing Under the Canada Health Infoway AI Scribe Program (the “Program”)" and "Automatic Termination Linked to Program End" detailed further down the page, immediately below this form.

I agree to generate a minimum of 10 notes per month.

I would like to discuss a group deal for my organization with a sales representative (6 users and more).