Consent for Communication Methods in Concierge Medicine Practice

Patient Information

Name: _________________________ Date of Birth: _____________ Email: _________________________ Phone: ___________________

Communication Preferences

Please indicate your preferences for the following communication methods:

Direct Communication

• Cell Phone
• Home Phone
• Work Phone
• Text Message
• Email
• Patient Portal

Voicemail Messages

I authorize detailed medical information to be left on my voicemail at:

• Cell Phone
• Home Phone
• Work Phone

Alternative Contacts

I authorize communication with the following individuals regarding my medical care:

Name: _________________ Relationship: _________ Phone: _________ Name: _________________ Relationship: _________ Phone: _________

Terms and Conditions

1. I understand that electronic communications are not always secure and may be intercepted by unauthorized parties.
2. I acknowledge that time-sensitive or emergency matters should not be communicated via email or text.
3. I understand that my physician will respond to communications within 24 hours during business days.
4. I agree to notify the practice of any changes in my contact information or preferences.

Direct Access Services

As a concierge medicine patient, I understand I will receive:

• 24/7 direct phone access to my physician
• Secure messaging through the patient portal
• Same-day or next-day appointments
• Extended visit times

Signature: _________________________ Date: _____________

Physician Signature: _________________ Date: _____________