Medical Communication Guidelines Acknowledgement Form
Please review and acknowledge your communication preferences and the outlined guidelines for medical-related correspondence.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Your Role or Relationship to Patient
*
Please Select
Patient
Parent/Guardian
Spouse/Partner
Authorized Representative
Other
Preferred Communication Channels
*
Email
Phone Call
SMS/Text Message
Postal Mail
Permitted Types of Medical Messages
*
Appointment Reminders
General Health Updates
Billing and Insurance Notices
Prescription Notifications
Other (please specify below)
How should urgent communications be handled?
*
Contact me by phone immediately
Send SMS/Text and follow up with a call
Email and phone call
Do you authorize a representative to receive communications on your behalf?
*
Yes
No
If yes, please provide the representative's full name and contact information
I have reviewed and acknowledge the Medical Communication Guidelines. I understand and agree to the stated communication preferences and permitted message types.
*
Submit Acknowledgement
Submit Acknowledgement
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