Home
About Us
Our Team
Quick Links
Services
Children and Baby’s Clinic
Family Practice and Walk In
Specialists
Immunizations
On Site Pharmacy
Book Appointment
MedChart
Contact Us
Email Policy
Menu
Home
About Us
Our Team
Quick Links
Services
Children and Baby’s Clinic
Family Practice and Walk In
Specialists
Immunizations
On Site Pharmacy
Book Appointment
MedChart
Contact Us
Email Policy
Book Appointment
Electronic Communication Consent Form
First Name
Last Name
Physician's Name
Email Address
Date:
*PATIENT ACKNOWLEDGEMENT AND AGREEMENT: I acknowledge that I have read and fully understand the Email Policy. I understand the risks associated with the use of communication by email between the Physician and me, and consent to the conditions outlined herein, as well as any other instructions that the Physician may impose to communicate with patients by e-mail. I acknowledge the Physician’s right to, upon the provision of written notice, withdraw the option of communicating through e-mail.
Send
