Consent to Leave a Message

This is a patient instruction form to the practice for handling your important medical information. This form is revocable at patient request in writing at any time.

Patient Name:

Date:

I wish to be called at (choose below) regarding my care and follow-up

Home # Other #

The best telephone number(s) to reach me are:

Home #:

Other #:

I DO or I DO NOT give permission to leave relevant medical information on my answering machine or voice mail. (choose below):

I DO I DO NOT

I DO or I DO NOT want relevant medical information shared with the person who may answer the telephone. (choose below):

I DO I DO NOT

The name(s) of the individual(s) with whom you may leave pertinent information are:

Add new row

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Patient Signature:

Date:

Your information will be encrypted.