CONSENT TO COMMUNICATE

Patient Name*

First NameLast Name

Family and Friends Contact

I give permission to the person(s) listed in the table below to receive information about my care. I understand my healthcare provider will use their professional judgment to ensure that information is shared with my family/friend in order to assist with my continuing care. This permission will be considered ongoing until I state in writing otherwise.

Name of Individual (First, Last)

Relationship to Patient / Phone number

Name of Individual (First, Last)

Relationship to Patient / Phone number

Name of Individual (First, Last)

Relationship to Patient / Phone number

Consent to Communicate Via Standartd SMS/TEXT Messaging

I hereby consent and state my preference to have my physician and staff at IDL MEDICAL PA to communicate with me by standard SMS messaging regarding various aspects of my medical care, which may include, but shall not be limited to, test results, prescriptions, appointments, and billing.

I understand that standard SMS messaging are not confidential methods of communication and may be insecure. I further understand that because of this, there is a risk that standard SMS messaging regarding my medical care might be intercepted and read by a third party.

By checking the box I acknowledge that*

I consent to communicate via messaging

Signature*