PatientConnect Consent

Medical Safety Inc. (MSI) is a company that specializes in healthcare software to bridge the communication gap between physicians and patients.

The PatientConnect application is currently in a pilot phase and is for communicating with patients and physicians to get feedback to optimize the application for future use.


To provide a professional and effective service, MSI needs to keep an encrypted record of Protected Healthcare Information.

Protected Healthcare Information includes your name and contact details, loved one’s name and contact details, DOB, and Sex.


MSI treats all personal information as private and confidential.


All communication and information are recorded on an encrypted database to prevent unauthorized access.


You have the right to see any information that MSI holds about you and to have your information removed.


MSI may compile statistical information for monitoring purposes, but this will never include identifiable patient information (PHI).


In giving your consent, you release the MSI and all third parties from liability for violating any Protected Healthcare Information (PHI).


You waive any proprietary rights you may have in connection with any sale, reproduction, or use of the PatientConnect application.

You agree to use your likeness on internet

You agree to allow to use your picture or family pictures with Doctors and Nurse for testimonial purpose


I have read and understood the information above and give my consent.