Patient Communication Consent Form - Gastroenterology

Patient Information

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

Communication Preferences

I, the undersigned, authorize [Practice Name] to communicate with me about my medical care, appointments, test results, and other healthcare information via the following methods:

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
  • General Health Information
  • Test Results
  • Patient Portal Instructions

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 confidential methods of communication and may be insecure
• I acknowledge that messages may be inadvertently accessed by others
• I understand that the practice will not send sensitive medical information via unsecured channels
• I can revoke or modify this consent at any time in writing

Signature: _________________________ Date: _________________

For Office Use Only

Received by: ______________ Date: _____________ Entered in EMR: [ ] Yes [ ] No