Consent form Demo

Home Phone/Voicemail–May we leave a message about health information?

YesNo

Work Phone – May we leave a message about health information?

YesNo

Cell Phone/Voicemail – May we leave a message about health information?

YesNo

Text Message – May we text a message about health information?

YesNo

Email – May we leave a message via email about health information?

YesNo

Also, you may request that we disclose or communicate your private health information to family members, other
relatives or close personal friends. If you wish to do so, please list their names and numbers.

Printed Patient Name:

Signature of Patient or Personal Representative

Date (expires in 2 years)