Patient Communication Consent Form - Cardiology Practice

Patient Information

Name: _________________________ Date of Birth: _________________ Medical Record #: ________________

Communication Preferences

I, the undersigned patient, authorize [PRACTICE NAME] to communicate with me using the following methods regarding my cardiac care, test results, appointments, and other health-related information:

Approved Communication Methods (check all that apply):

• Cell Phone: ________________

  • Voice Messages
  • Text Messages

• Home Phone: ________________

  • Voice Messages
  • Detailed Messages
  • Brief Messages (callback requests only)

• Email: ____________________

  • Appointment Reminders
  • Test Results
  • Educational Materials

Authorized Representatives

I authorize the practice to discuss my medical information with:

1. Name: ________________ Relationship: _________ Phone: _________
2. Name: ________________ Relationship: _________ Phone: _________

Acknowledgments

• I understand that email and text messaging are not secure forms of communication
• I acknowledge that cellular/wireless carriers may charge for messages
• I understand I can revoke this consent at any time in writing
• I have been informed about the practice's privacy policies

Signature: ______________________ Date: ____________

Witness: ________________________ Date: ____________