KAP Communication Consent

Please correct the errors described below.

Use of Electronic Communications Via SMS, Email & Portal

This consent excludes communicating with guardian/patient regarding practice updates, changes, appointment reminders via email, sms or portal. This consent is in regards to medical release information between our office/doctor(s) in addition to the items below:

Patient Portal Access Includes:

  • View and request appointments
  • View and print immunization records for school and day care
  • Prescription refills
  • Retrieve test/lab results
  • View billing statements
  • Secure payments for balances
  • Secure messaging with our office staff, billing and/or doctors
  • Referrals Requests
  • Immunizations Records

For routine matters that do not require immediate response, we ask that you contact our office through the Patient Portal . Please remember however, that this form of communication is not appropriate for use in an emergency. The turnaround time for routine patient communications is approximately one-three business day. Should you require urgent or immediate attention, please contact our office directly. Communications relating to diagnosis and treatment will be filed in patient(s) file.

Additional Patient

Must Be Different From Father
Must Be Different From Mother
Must Be Different From Father
Must Be Different From Mother

Patient Portal Access

By signing this form, I attest that I have personally read this form (or had it explained to me) and fully understand and agree to its contents.

This will be used for contact purposes only

Your message will be encrypted and can only be read by Kid Approved Pediatrics.