Patient Communication Consent Form - Vascular Surgery

Vascular Surgery Department

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

Approved Communication Methods

(Check all that apply)

• Cell Phone: (_____) _____ - ________

  • Voice Messages
  • Text Messages

• Home Phone: (_____) _____ - ________

  • Voice Messages
  • Detailed Messages

• Email: ________________________________

Authorized Individuals

I authorize the practice to discuss my medical information with:

1. Name: ___________________ Relationship: ____________ Phone: __________________ Access Level: [ ]Full [ ]Limited

2. Name: ___________________ Relationship: ____________ Phone: __________________ Access Level: [ ]Full [ ]Limited

Understanding & Acknowledgment

• I understand that electronic communications are not always secure
• I accept the risks associated with these communication methods
• I understand I can modify or revoke this consent at any time
• This consent remains valid until written notice of change is provided

Signature: ______________________ Date: ___________

Practice Representative: __________ Date: ___________