Communications

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?*

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Patient Signature*

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Patient Name*
Date*

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Patient Name
I grant permission to discuss my care and/or information in my records with the following person(s):
Name
Date

MonthDay Year
Name
Date

MonthDay Year
Patient Signature*

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Date*

MonthDay Year
Should be Empty: