Email Consent Form

Burgess Pediatrics Email Communication Consent Preferences

Patient Name:

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):

Email me about appointment reminders and other administrative matters.

I WILL accept regular emails and texts containing medical information.

Do not email me.

I ONLY want to receive medical communication via Elation Passport. Please send me a link to sign up for Passport. A unique email address is required below for each child that you wish to enroll.

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.

Primary Parent/Guardian Name:

Email(s):

(one for each child if enrolling in Passport)

Secondary Parent/Guardian Name:

Email:

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.

Signature:

Date:

Your information will be encrypted.