AI SCRIBE CONSENT FORM

[Clinic name]
[Address and phone]

Patient: [Full name]
Date of birth: [Date]
Clinician: [Name and credentials]

WHAT THE AI SCRIBE DOES
Your clinician uses an AI scribe called [AI scribe name] to help write visit notes. It listens to your visit and writes a draft of the note. Your clinician reads every draft, corrects it, and signs the final note. The AI scribe does not make decisions about your care.

WHAT IS RECORDED
Captured: [Audio of the visit, a written transcript, or both]
Others in the room: [Anyone else whose voice may be captured, e.g. a family member or interpreter]

WHERE IT IS PROCESSED AND STORED
Vendor: [Company that runs the AI scribe]
Location: [Where the audio and transcript are processed and stored, e.g. in Canada]
Training: [Whether your information is used to train the AI, e.g. not used]
Deleted: [When the audio and transcript are deleted, e.g. once your clinician signs the note]
Kept in your health record: [The signed note only, or anything else the clinic keeps]

RISKS AND SAFEGUARDS
The draft can contain mistakes, leave things out, or reflect bias. Any digital system carries some privacy risk.
Safeguards: [e.g. encryption, access limited to your care team, a privacy agreement with the vendor]
Your clinician checks every note before signing it.

YOUR CHOICE
Using the AI scribe is your choice. Saying no will not change your care. You can ask your clinician to pause or stop it at any time, and you can change your mind at a later visit. Without it, your clinician takes notes the usual way.
Questions: [Who to ask, e.g. the clinic's privacy contact and phone]

CONSENT
I agree to the use of the AI scribe: [Yes or no]
This consent covers: [This visit only, or this and later visits until I say otherwise]
Name: [Patient's name, or the substitute decision-maker's name]
Relationship to the patient: [If not the patient, e.g. parent or guardian]
Signature: [Signature, or verbal consent recorded by the clinician]
Date: [Date]

FOR THE CLINICIAN

Script, before you turn it on:
I use an AI scribe called [AI scribe name] to help write my notes. It listens to our conversation and drafts the note, and I check and correct all of it before I sign. The [audio or transcript] is processed [where] and deleted [when]. It can make mistakes, and any computer system has some privacy risk. You don't have to agree, and saying no won't change your care. You can ask me to stop it at any time. Is it OK if I use it?

At later visits:
Just a reminder that the AI scribe is on today. Tell me any time if you'd like it off.

Line for the chart:
AI scribe: [AI scribe name] used with [verbal or written] consent from [the patient, or the name and relationship of the substitute decision-maker] on [date]. Explained its purpose, that I review every note, what is recorded, where it is processed and when it is deleted, the risks of errors and to privacy, and the right to decline or stop at any time. Consent covers [this visit, or later visits until withdrawn].