CONSENT TO BE CONTACTED FOR POST-VISIT SATISFACTION SURVEY FORM

CONSENT TO BE CONTACTED FOR POST-VISIT SATISFACTION SURVEY FORM
Name

First NameLast Name
Client's DOB
Capstone Behavioral Health (“Center”) is committed to ensuring patients’ satisfaction of services received.
Center has contracted with a third party – Burke, Inc. – to conduct satisfaction surveys on our behalf. The survey
will be provided online and will take no more than 10 minutes to complete. If you agree to be contacted to
participate in a survey about our services, please indicate your consent by checking one of the boxes below:
I agree to be contacted by Burke, Inc. via email (at the email listed below) for purpose of the survey andunderstand that the invitation will mention Center. I acknowledge and agree that these messages, which maycontain Protected Health Information, will be sent via unencrypted means and there is some risk of disclosure orinterception of the messages.
Email Address:
example@example.com
I understand that this consent may be withdrawn by me at any time via the email I receive from Burke, Inc., via
telephone by calling 402-614-8444 or via email message at info@capstonebehavioralhealth.com. I understand
that my withdrawal of consent to be contacted for a post-visit satisfaction survey shall not withdraw my consent
to otherwise by contacted by Center.
I do not wish to be contacted for purposes of this survey.
Signature

I confirm that I have read and fully understand the above information prior to my signing and all of my questions
regarding this form have been answered to my satisfaction. I agree that I am signing this Consent to be
Contacted for Post-Visit Satisfaction Survey Form freely and voluntarily. I understand that my consent given with
my signature below will remain in effect unless and until I cancel such consent in writing pursuant to the terms set
forth above.
Signature of Patient or Responsible Party

Clear
Date

MonthDayYear
Date
Printed Name of Patient (or Responsible Party):
Responsible Party’s Relationship to Patient:
Should be Empty: