Email Consent Form
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The Austin Diagnostic Clinic E-Mail Conditions of Use and Disclaimer Policy

Communication technology has changed in the past 5 years. More and more information is being shared via the Internet, particularly through the use of e-mail. The Austin Diagnostic Clinic wishes to provide an organized framework and a set of guidelines and expectations to ensure appropriate and consistent use of clinic/patient e-mail at ADC.

Conditions for the Use of E-mail

The Austin Diagnostic Clinic will use reasonable means to protect the security and confidentiality of e-mail information sent and received. However, ADC cannot guarantee the security and confidentiality of e-mail communication, and will not be liable for improper disclosure of confidential information that is not caused by ADC’s intentional misconduct. Thus, patient consent to the use of e-mail is required and includes agreement with the following conditions.

Instructions

To communicate by e-mail, you are requested to:

Response Time

Risks of Using E-Mail

Transmitting information by e-mail has some risks that you should consider before using e-mail. These include, but are not limited to:

Your Acknowledgment and Agreement

I acknowledge that I have read and fully understand the E-Mail Disclaimer Form.

I understand the risks associated with the communication of e-mail between The Austin Diagnostic Clinic and me, and consent to the conditions outlined in the Disclaimer.  In addition, I agree to the instructions outlined in the disclaimer, as well as any other instructions that ADC may impose to communicate with patients by e-mail.

10/02

Permission Form: (All fields with an * are required)

*Yes, I give permission for ADC to contact me using email for any and all communication purposes.  (ADC will not share or divulge my email address with/to any third party)
*First Name:  
Middle Name/Initial:
*Last Name:   
*Social Security No.:   (For patient identification purposes only)
*Birth Date: 
*Address1:  
Address 2:
*City:   
*State:  
*Zip:  
 *email address:   (e.g. emailname@yourdomain.com)
  Provider
Your Primary ADC Physician:
Other ADC Physicians that you see: 
 #1:  
#2: 
#3: