May we phone, email, or send a text to you to confirm appointments or post patient satisfaction surveys after visits?

    May we leave a message on your answering machine at home or on your cell phone?

    May we discuss your medical conditions with any member of your family?

    If so who?

    Please sign below:


    Date Signed:


    Go Back to New Patient Form

    Safe External Link

    Go Back to General Forms

    Go Forward to Financial Policy