Patient-Provider Communication Consent Form

This form allows us to communicate with you regarding your care. Please review and complete the information below.

Patient Information

Full Name Date of Birth

Consent for Communication

I consent to be contacted by my healthcare provider using the following methods for purposes related to my care:

• Phone
• Email
• Text Message

Phone Number Email Address

Details of Communication

Patient Acknowledgement

I understand that communications may not be secure and there is a risk of my information being accessed by unauthorized persons. I accept these risks and consent to receive communications as indicated above.