Consent for Communication Via E-mail Header Image

Consent for Communication Via Email (Clinician-Patient)

I,
(Name)*
hereby consent to have my physician,
(Physician's Name)*

, and his staff communicate with me through email whenever he/she deems this to be appropriate. I furthermore agree to have my physician use email communication with other physicians, nurses, laboratory personnel, administrative and other staff members, as he/she deems necessary and appropriate, to facilitate my medical care and treatment.

I understand that GENESIS uses a SECURE E-MAIL that provides confidentiality, but cannot ensure that your e-mail account itself is secure. I further understand that there is a risk that e-mail communications between my physician and me or members of my physician’s office staff, or between my physician and other physicians, and staff, including responsible parties not affiliated with my physician’s practice, such as referring physicians and pharmacists, regarding my medical care and treatment may be intercepted by third parties or transmitted to unintended parties. I understand that GENESIS FERTILITY does utilize an encryption software program to minimize the risks of such interceptions.

I also understand that any e-mail communications between my physician and me or members of his/her office staff, or between my physician and other physicians, nurses, laboratory personnel, administrative and other staff members, regarding my medical care and treatment may be printed out and made a part of my medical record.

I understand that in an urgent or emergent situation I should call my physician or go to the Emergency Room and not rely on e-mail.

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