CONSENT TO BE CONTACTED FOR POST-VISIT SATISFACTION SURVEY FORM

Patient Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Patient Date of Birth: (00/00/0000)*

Northlight Counseling Associates 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 IO 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:

You agree to be contacted by Burke, Inc. via email (at the email listed below) for purpose of the survey and understand that the invitation will mention Center. I acknowledge and agree that these messages, which may contain Protected Health Information, will be sent via unencrypted means and there is some risk of disclosure or interception of the messages.*

I Agree

Email*

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I understand that this consent may be withdrawn by me at any time via the email I receive from Burke, Inc., via telephone by calling 602-285-9696 ext#205] or via email message at karballo@northlightcounseling.net 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.

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: *

Printed Name of Patient for Responsible Party:

First NameLast Name

Responsible Party's Relationship to Patient: