Patient Intake/Consent Form - ValleyCare Medical Clinic

Electronic Communication Consent Form for ValleyCare Medical Patients

Doctor or Nurse Practitioner Name: *

Patient Acknowledgement & Agreement:

Please read the above and fill out the fields below to acknowledge this agreement.

Patient name: *

First

Last

Patient address: *

mailing address: street, city, postal code

Patient health card #: *

Patient date of birth (Day, Month, Year): *

Patient home phone: *

if you do not have a home phone, typing N/A is sufficient

Patient cell phone: *

if you do not have a cell phone, typing N/A is sufficient

Preferred phone for contact: *

Email: *

Would you like the following (check which apply)? *

appointment reminders are sent automatically via email the day before appointment
updates/newsletters sent via email

Preferred pharmacy: *

name & city of location

Date submitted & initials: *

Appendix

If email or text is used as the form of communication:

Conditions of using the services:

Phone