Patient Communication Consent Form - Dermatology Practice

Patient Information

Name: ___________________________ Date of Birth: _______________ Medical Record #: _________________ Date: _____________________

Communication Preferences

I, _________________________, authorize [Practice Name] to communicate with me using the following methods regarding my medical care, appointments, test results, and other protected health information:

Electronic Communication (select all that apply)

• Email: ___________________________
• Text Messages: ____________________
• Patient Portal Messages
• Voicemail Messages

Authorized Representatives

I permit the practice to discuss my medical information with:

Name: _______________ Relationship: _____________ Phone: ___________ Name: _______________ Relationship: _____________ Phone: ___________

Acknowledgments

I understand that:

• Electronic communications are not always secure and may be intercepted by unauthorized parties
• The practice will use minimum necessary information in communications
• Urgent or emergency conditions should not be addressed through email or text
• I can revoke this consent at any time in writing

Privacy Notice

The practice will not share your contact information with third parties for marketing purposes. Standard message and data rates may apply for text messages.

Patient/Guardian Signature Date

Witness Signature Date