By signing below, I consent to the use of email communication between myself, __{nameOfPatient}__ and Dr. Gomez. I recognize that there are risks to its use, and despite Dr. Gomez’s best efforts, she cannot absolutely guarantee confidentiality. I understand and accept those risks and the policies for email use outlined in the form. I further agree to follow these policies and agree that should I fail do so, Dr. Gomez may cease to allow me to use email to communicate with her. I also understand that I may withdraw my consent to communicate via email at any time by notifying Dr. Gomez in writing.