Email Consent Form

PATIENT / PARENT CONSENT FOR USE OF EMAIL COMMUNICATIONS

Please note: Emails are for NON EMERGENT communication ONLY, not for appointment scheduling.

lf sending email, please put the subject of your message in the subject line so we can process it more efficiently. Also, be sure to put your name, patient name with date of birth, and return telephone number in the body of the message. We also ask that you acknowledge receipt of emails coming from this office by using the auto reply feature.

lf you send an email on behalf of your child with a clinical question, you MUST also call the office and leave a verbal message.

Communications relating to dlagnosls and treatment will be filed in your child's medical record.

This office is dedicated to keeping medical record information confidential. Despite our best efforts, due to the nature of email, third parties may have access to messages. When communicating from work, you should be aware that some companies consider email corporate property and your messages may be monitored. Even when emailing from home, you may feel that access to your email is not well controlled, so you should take that into consideration. ln addition, you should be aware that, although addressed to me, my staff and/or colleagues would have access to this information.

I understand that this office will not be responsible for information loss or delay or breaches in confidentiality that are due to technical factors beyond this office's control.

I understand and agree to the above email policy.

By signing below, you are agreeing that we may send medical related correspondence to you via email, and that we may respond to your emails to us via email.

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

Patien/Parent Signature

Date

Patient Name

Email address

Your information will be encrypted.