Nutrition Services Communication Consent Form

Patient Information

Name: ___________________________ Date of Birth: _______________ Phone: ___________________________ Email: ______________________

Communication Preferences

Please select your preferred methods of communication (check all that apply):

□ Phone Call □ Text Message □ Email □ Patient Portal □ Mail

Authorization for Communication

I hereby authorize [Practice Name] to communicate with me regarding:

• Appointment reminders and scheduling
• Nutrition care plans and recommendations
• Laboratory and test results
• Billing and insurance matters
• Educational materials and resources
• Follow-up care instructions

Information Sharing Authorization

I authorize the sharing of my nutrition-related information with:

□ Primary Care Physician □ Other Healthcare Providers (specify): _____________________________ □ Family Members/Caregivers (specify): ____________________________

Electronic Communication Acknowledgment

I understand that:

• Electronic communication may not be secure
• Response times may vary
• Emergency situations require immediate phone contact or emergency services
• I must notify the office of changes to my contact information

Signature

Patient/Guardian Signature: _________________ Date: _______________

Print Name: ______________________________ Relationship: __________

Office Use Only

Received by: _____________________________ Date: _______________