By submitting this form, you confirm that you have received client or patient authorization to provide the personal information above to the Burnaby Division of Family Practice (the “Division”) for the purpose of a referral for services through its Social Prescribing program. You also confirm that you have received authorization from the client or patient for the Division to collect, use and disclose additional information about the patient from and to you for that purpose. Finally, you confirm that you have informed the client or patient of their right to withdraw consent at any time by contacting privacyofficer@doctorsofbc.ca, though withdrawal may affect the Division’s ability to provide the requested services. Please note that all personal information received by the Division is handled in accordance with the Personal Information Protection Act of British Columbia, and in accordance with the Doctors of BC Privacy Code, which is available at the following link: https://link.edgepilot.com/s/e0f52dba/i4NwbHIb-kmz-Fh7n51nQw?u=https://divisionsbc.ca/footer/privacy. If you or the client/patient have any questions about how patient information is used or managed, please contact the Doctors of BC privacy officer using the above details.