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Email/Text messaging consent form
TOCDOC, 411 Clarendon Court, Suite 104, Savoy, IL 61874, Phone: 815-6836109, Email: firstname.lastname@example.org
Email and Text Messaging Consent
I hereby state my preference to have my physician, Dr. Nitin Bhosale, and other staff at TOCDOC communicate with me by email or standard SMS messaging regarding various aspects of my medical care, which may include, but shall not be limited to, test results, prescriptions, appointments, and billing. I understand that email and standard SMS messaging are not confidential methods of communication and may be insecure. I further understand that, because of this, there is a risk that email and standard SMS messaging regarding my medical care might be intercepted and read by a third party. I understand that TOCDOC provides me access to a HIPAA compliant patient portal that can be used for secure messaging with the practice. I also understand that I can withdraw this consent at any time by resubmitting this form to TOCDOC (selecting "No" as an option)
I consent to email/text messaging communication with TOCDOC
Name (First, Last)
Date of Birth
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