HIPAA Compliance & Patient Consent Form Name: Your Email (required) Text message phone number Voicemail phone number May we phone, email, or send a text to you to confirm appointments or post patient satisfaction surveys after visits? yesno May we leave a message on your answering machine at home or on your cell phone? yesno May we discuss your medical conditions with any member of your family? yesno If so who? Please sign below: Date Signed: Go Back to New Patient Form Click HereSafe External Link Go Back to General FormsClick HereGo Forward to Financial PolicyClick Here
