AUTHORIZATION TO COMMUNICATE VIA ELECTRONIC MEANS- Bradenton Aesthetics

AUTHORIZATION TO COMMUNICATE VIA ELECTRONIC MEANS
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Patient Name*
I, the undersigned, hereby consent to Bradenton Aesthetics communicating with me via the following electronic means to share/communicate about my treatment and/or Health Record as defined in the Notice of Privacy Practices: (Choose One)*

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Bradenton Aesthetics may

Leave a message to call backProvide information about my treatment and/or Health Record on my voicemail
Revocation and Expiration

Unless sooner terminated, this authorization shall expire one (1) year after the date of its execution. I understand I may terminate this authorization at any time to prohibit future communications regarding my treatment and Health Record. To terminate this authorization, I understand I must send a written notice to Bradenton Aesthetics at jaymee@bradentonaesthetics.com or 2310 Manatee Avenue W, Bradenton, FL 34205.

Acknowledged:

I have read this form in its entirety. I acknowledge and agree I have been given the opportunity to ask any questions relating to this form and had all questions answered to my satisfaction.
I will print a copy of this authorization for my records.
Patient Signature*

Clear
Date*

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2310 Manatee Avenue W, Bradenton, FL 34205
watsonjay3131@gmail.com
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