Patient Data Re-advertising Consent

Patient Name:

Date of Birth:

Contact Information:

Medical Record Number:

Consent Statement

I hereby give my consent for the use of my health information and associated data for the purposes of re-advertising, communication, and outreach by the healthcare provider, in accordance with applicable privacy laws and regulations.

I consent to the use of my patient data for re-advertising purposes.

I do not consent to the use of my patient data for re-advertising purposes.

Signature:

Date:

Witness (if required):

Date: