Patient Communication Form

From time to time in caring for our patients, it may become necessary to contact you by telephone. Often our patients are not available when we call them and we would like to be able to leave detailed telephone messages (i.e. lab results) when possible. There are also times where you may want us to communicate labs, medication, treatment plans, or billing information to a trusted family member. In order to protect your privacy we need your written permission to leave detailed telephone messages on your answering machine, voice mail system, or with a trusted family member.

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  • Please choose one of the following for the providers and staff:

  • Deny or Revoke Consent

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