Patient Communication Authorization and Consent Form

Patient Information

Name: _________________________ Date of Birth: _____________ Chart Number: __________________ Date: ____________________

Communication Preferences

I authorize [Practice Name] to communicate with me using the following methods (check all that apply):

• Cell Phone: (_____) _____ - ________

  • Voice Messages
  • Text Messages

• Home Phone: (_____) _____ - ________

  • Voice Messages
  • Detailed Messages
  • Brief Messages Only

• Email: ____________________________

Authorized Individuals

I authorize [Practice Name] to discuss my medical information with:

1. Name: _________________ Relationship: _____________ Phone: ____________
2. Name: _________________ Relationship: _____________ Phone: ____________

Communication Content Authorization

I authorize communication regarding (check all that apply):

• Appointment Reminders
• Pre/Post-operative Instructions
• Prescription Information
• Billing/Insurance Matters
• Test Results
• Treatment Planning

Understanding and Agreement

• I understand that email and text communications are not encrypted and may not be secure
• I acknowledge that cellular/mobile charges may apply to text messages
• I understand I can modify these preferences at any time by submitting a new form
• This authorization remains valid until revoked in writing

Signature: _________________________ Date: _______________

Print Name: ________________________