Urgent Care Patient Communication Consent Form

Patient Information

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

Communication Preferences

I authorize [Urgent Care Name] to contact 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: ____________________

  • Appointment Reminders
  • Test Results
  • General Health Information

Authorized Recipients

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

Name: _________________ Relationship: __________ Phone: __________ Name: _________________ Relationship: __________ Phone: __________

Acknowledgment

I understand that:

• Communication through electronic means carries some risk to privacy
• Urgent medical issues should not be addressed through email or text
• I can revoke this consent at any time in writing
• This consent remains valid until revoked

Signature: _________________________ Date: _____________

For Office Use Only

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