I understand that if my protected health information is to be transferred by email, certain risks are inherent to this method of communication.
*
I authorize the use of email for communication.
I do not authorize the use of email for communication.
Do we have your permission to text you for communication?
*
Yes
No
Patient Signature
*
Patient Name
*
Date
*
-
Month
-
Day
Year
Patient Name
I grant permission to discuss my care and/or information in my records with the following person(s):
Name
Date
-
Month
-
Day
Year
Name
Date
-
Month
-
Day
Year
Patient Signature
*
Date
*
-
Month
-
Day
Year
Submit
Should be Empty: