Patient Email / Text Consent Form – Awareness of Use If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Doctor's Name: Dr. Ping Jaa Dr. Paul Payton Dr. Jane Chapman Dr. David Jaa I, (patient's name): * Patient Date of Birth: * Patient Email Address: I confirm I wish to communicate with Dr. Jaa's Medical Health via email/text and I understand that: It is my request to use email / text; Email / text is not a totally secure system for sending and receiving information; Any decision to use email / text communication will be documented in my clinical records; Emails may be printed and stored in my clinical records; Text communications may be documented in my clinical records; No emails - either sent by me or the staff member will be forwarded to anyone else with consent of any party; Any decision made by myself to stop the use of email / text will be respected upon written notice. Any resumption will therefore require a new Consent Form; Confidentiality will be respected by staff at all times. I am signing to confirm that I have understood the conditions as set out above and have been made aware of the associated risks with regards to data protection. CONSENT: Patient Name: * Date: * Confirm that you are not a bot *
