Email Consent Form

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Burgess Pediatrics Email Communication Consent Preferences

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At Burgess Pediatrics we are able to use email to communicate with you about routine matters such as appointments, follow-up inquiries, prescriptions and certain laboratory and x-ray studies.

However, we recognize that email is not a secure communication method and should be considered as visible as a postcard. Breaches in confidentiality and failure to transmit information can occur by errors in sending, email interception, server intrusions and other events. Email is also not appropriate for real-time communication about urgent medical matters. Other communication methods available at Burgess Pediatrics include telephone calls and messaging through Elation’s secure Passport, our electronic medical record program. Knowing this, please indicate your email preferences. (Check all that apply):

I/we authorize the physicians and staff at Burgess Pediatrics to communicate with us based on the choices on this form and acknowledge that email is not secure. I will notify Burgess Pediatrics immediately if these email addresses or my/our preferences change.

(one for each child if enrolling in Passport)

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

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