Patient Communication Information

Blue Ridge Pediatrics, LLP

Please correct the errors described below.

Patient Name:

DOB:

In order for us to better communicate with our patients we are asking all patients to fill out this Patient Communication log.

Have you accessed our Patient Portal?

Yes No

If No, Would you like to access our Patient Portal?

Yes No

If Yes, Please print your Email Address here:

When we activate your email address you will receive an email confirmation from us. This will include the link to our portal, your log in and your password. If you forgot your log in and/or password the Receptionist can reset your password for you today

Do you want to reset your log in and password?

Yes No

How would you like us to confirm your appointment? You can select one or both.

By Voice Mail?

Yes No

By Text (SMS) message?

Yes No

What is your preferred phone#?

Is this your Home, Work or Cell Number? (Please select one)

Home Number Work Number Cell Number

What is your preferred language?

English Spanish

Preferred time to call you?

Morning Afternoon Evening

Is there any special information you would like us to add to your child’s account in reference to how we should contact you?

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 or Guardian’s Signature:

Today’s Date:

BRP Employee’s Initials:

Scanned:

Entered in ECW:

Your information will be encrypted.

Electronic signature

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I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

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