Template Document
Resident Consent Form
Template for care facilities. Customize with your facility name before use. Click “Print” to save as PDF.
CONSENT FOR AI WELLNESS CHECK-IN SERVICES
Powered by WellAI (wellai.ca)
Facility Information
Facility Name
Date
Resident Information
Resident Full Name
Room / Unit Number
Phone Number
Preferred Contact Method
About This Service
WellAI is an AI-powered wellness check-in system that will contact you (or your loved one) via text message or phone call at scheduled times each day to ask how you are feeling. Your responses are analyzed by artificial intelligence to detect mood changes, distress, or potential health concerns. If a concern is detected or if you do not respond, designated caregivers and/or family members will be automatically notified.
What You Are Consenting To
By signing this form, you (or the authorized representative) consent to the following:
- Receiving automated SMS text messages and/or phone calls from WellAI at times scheduled by the facility (typically twice daily)
- Your responses being recorded, transcribed, and analyzed by artificial intelligence for wellness monitoring purposes
- AI-generated mood scores and wellness indicators being stored and shared with your designated caregivers and/or facility staff
- Designated contacts being automatically notified if distress is detected or if you do not respond to a check-in
- Your data being processed by WellAI's technology partners (Twilio for communications, Anthropic for AI analysis) as described in WellAI's Privacy Policy at wellai.ca/privacy
Important Information
Not a medical service: WellAI is a communication and monitoring tool. It is not a medical device, does not provide medical advice, and is not a substitute for professional healthcare.
Not an emergency service: WellAI does not replace 911 or emergency services. In case of a medical emergency, call 911 immediately.
AI limitations: AI analysis may not always accurately detect distress or health changes. Human judgment and professional care remain essential.
Your Rights
- You may withdraw consent at any time by replying STOP to any WellAI message, or by asking facility staff to remove you from the service
- You may request access to or deletion of your data by contacting the facility or WellAI at privacy@wellai.ca
- Withdrawing consent will stop all automated check-ins but will not affect any other care you receive
Consent Signatures
I have read and understand this consent form. I voluntarily agree to participate in WellAI wellness check-ins.
Resident Signature (or Mark)
Date
If the resident is unable to provide consent, the following authorized representative consents on their behalf:
Representative Name
Relationship to Resident
Representative Signature
Date
Witnessed by facility staff:
Staff Name & Title
Staff Signature & Date