HEARTS Informed Consent for Participation

Welcome to RDPCN programs!  We are here to support and learn with you . We want you, and other group members, to have a positive experience during the program.  We ask you to review, and sign the following consent form.
At this time, and due to the COVID-19 virus pandemic, virtual programs will provide you with easier access to workshops and the convenience of communicating from your home.
To participate in the virtual group setting you will require a computer that has access to both audio and camera. A laptop, tablet, or cell phone will work.  Email will also be required for sending/receiving materials for the group (consent form and evaluation forms).

RDPCN Responsibility

  • Provides group programs to the public.
  • Provides trained health professionals to facilitate the groups.
  • Provides a safe environment for group programs.

Participant Responsibility


  • Please make every effort to attend on time.
  • You may withdraw from the group at any time.
  • If you do not wish to remain in a group, discuss the potential benefit of other resources with the facilitators through the chat option.


  • To get the most benefit and growth from our groups try the activities and participate in discussions. Virtual group participation and email technology will not be the same experience as in-person. However, the facilitators strive to ensure a positive group experience.  There may be times, when they, or any group participant, may miss or misunderstand typical conversational/visual cues. The chat feature is available for asking for clarification by both facilitators and participants.
  • Some topics may be uncomfortable for you; you have the option to decline to answer a question or take part in an activity. Feel free to discuss this with your facilitator through the chat option.
  • Treat other group members with the same courtesy that you would like to receive. Please refrain from providing unsolicited advice.  Encouragement and validation are appropriate.
  • Safety is of utmost importance, therefore verbal harassment to others will not be tolerated.  Anyone who violates this rule will be removed from group and will be called by the facilitator to discuss expectations for returning.


  • Please mute your screen unless talking.  Ensure you have access to video/ audio options on your computer and Wi-Fi.  Ensure others are not using your Wi-Fi at the same time or using the microwave for the best experience.
  • The RDPCN is not responsible for any data overage fees accrued during group. These fees are the client’s sole responsibility.
  • Give a group facilitator a thumbs up if you need to leave the room before a break so they know that you are okay.  If you are gone for more than 5 minutes, one of the facilitators will call to check on you after class.


RDPCN conducts evaluation of all programs.  Your involvement and feedback helps us ensure high quality programs.
  • All evaluation is voluntary.
  • Any information you provide will be kept confidential, used only for the purposes of evaluating the program.  Any reports that are produced about the program will combine data from all participants and ndividual participants will never be identified. 
  • In order to show progress and as part of the care provided by the RDPCN, it may be necessary to communicate aspects of the evaluation results with your family physician.

Confidentiality (Protections and Limitations)

  • All information shared by the participant will be kept confidential within the group.  Please ensure you are in a quiet and private location to ensure confidentiality for yourself and other participants.  The use of headphones is advised.
  • A letter will be sent to your physician about your participation in the group and kept on your medical file.
  • No information will be released to any other party except:
    • If there is a risk of harm to the participant or others,
    • If there is a risk of harm to a child or other vulnerable person,
    • If a lawyer subpoenas the records for a court case.
I understand there are potential risks to virtual groups, including interruptions, risk of distractions, unauthorized access, time delays, equipment failure, and technical difficulties.  There are other risks using a virtual platform, for example others overhearing the conversation, and the potential of hackers. 

Today's Date

Client / Guardian

First Name

Last Name

Client Alberta Health Care Number

Client Phone Number

Client Address

Name of Family Doctor

Name of Clinic

Location of Clinic

Emergency Contact Name

Emergency Contact Phone Number

 Information on this form is collected under the authority of section 33(c) of FOIP and/or section 20(b) of HIA (pursuant to sections 27.1 and 27.2 of HIA) for the purposes of providing health services and carrying out planning and resource allocation, health system management, public health surveillance and health policy development. For more information about the collection of information on this form, please contact the Executive Director, Red Deer Primary Care Network at 403.343.9100.


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