Patient Email / Text Consent Form – Awareness of Use

Fields marked with an * are required

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:

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