Patient Communication Consent -

Name * Date Of Birth *

Patient Communication Consent: We may need to contact when you are not in the office. This is to acknowledge that you authorize us to:

Leave a detailed message on voicemail. Yes No

Leave a detailed message with individual answering the phone. Yes No

Email you using an encryption software. Yes No

Text you. You understand that standard charges will apply through your mobile carrier. Yes No

By typing my name below, I authorize staff and providers at rheumatology center of Houston to contact me using the above modalities. I understand the risks and benefits of each of the above options. Date