on Voice Mail, Answering Machines or with Family Members
Please correct the errors described below.
At Amber Pediatrics, we understand that communication is an important part of the patient/health care provider relationship. In order to relay important information to our patients’ guardians in a timely manner, we may often need to leave messages on voice mail, answering machines or with family members:
Please provide the telephone numbers where we may contact you:
Detailed Voice Mail and Answering Machines Messages
In some cases when we are unable to speak with you directly, we may need to leave a voice mail or answering machines message with detailed information about your child’s condition or treatment (such as the results of tests or the scheduling or procedures). You should be aware that other individuals who have access to your voice mail or answering machine could hear these messages. At home this may mean that other members of your family could hear these messages. At work it may mean that your employer could hear these messages.
Please tell us at which numbers we MAY leave a DETAILED voice mail message:
Messages with Family Members or Others Who Answer Your Home Phone
We may also need to leave messages with detailed information about your child’s condition or treatment, such as the results of tests or the scheduling of procedures, with family members, or others who answer your home telephone.
Please tell us if we may leave DETAILED messages with individuals who answer your home telephone, please indicate below:
My signature below indicates I have read and understand the above notice regarding consent to leave detailed messages.
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.