Email Consent Form

Name of patient:*
First Last
Preferred Email Address:*
Consent*
I consent to the email policy
Hereby consent to have my physician, Dr. Bradley Kropp and/or Jake Klein APRN to communicate with me or members of the staff, where appropriate, other physicians, nurse practitioners, and clinicians via e-mail regarding the following aspects of my medical care and treatment: test results, prescriptions, appointments, billing, etc. I understand that e-mail communications are not a confidential method of communication. I further understand that there is a risk that email communications between my physician and other physicians, nurse practitioners and pharmacists regarding my medical
care and treatment may be intercepted by third parties or transmitted to unintended parties. I also understand that any e-mail communications between my physician and me or members of this office staff or between my physician and other physicians, nurse practitioners or pharmacists regarding my medical care and treatment will be printed out and made a part of my medical record. I understand that in the urgent or emergent situation, I should call my provider or go to the nearest emergency room and not rely on e-mail.

I have also read the Notice of Privacy Practices.
Name of patient/parent/guardian:
First Last
Date*
Date Format: MM slash DD slash YYYY
Name
This field is for validation purposes and should be left unchanged.