Authorization for Protected Communication
I (the person named below) prefer to be contacted in the following manner.
Patient portal – Preferred E-mail Address
example@example.com
Telephone – Preferred Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Written Communication – Home Address
Other
Access to Information
Pavilion Family Medicine may share or access medical information about me from/with the following person(s):
Please list Name - Relationship - Telephone # - Is this person also an emergency contact? (Yes/No)
Patient Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: