Informed Consent for E-Mail or Text Communication

Record #

Informed Consent for E-Mail or Text Communication

The use of e-mail and/or text communication can improve the ability to exchange information quickly and efficiently between you and your health care provider.  The confidentiality of the information exchanged by e-mail and/or text messages is not guaranteed.  Messages sent are not encrypted and can potentially be misdirected or intercepted by unintended parties.  In addition:

  • E-mail and/or text messages may be processed by staff other than your health care provider.
  • E-mail and/or text messages sent to workplace e-mail and/or text addresses may be monitored by employers who may have the right to monitor all workplace e-mail and/or text communications.
  • E-mail and/or text messages or relevant information from the message may be filed in your health record by your health care provider.

Please review the following guidelines outlining the acceptable use of e-mail and text messages between clients and health care providers within our practice.

  • Do not use e-mail or text messages for urgent matters. Your health care provider may be away from the workplace or may not be able to check e-mail or text messages daily.  Another method of communication should be used.
  • Do not use e-mail or text messages for information you consider sensitive and would not want shared with anyone except your health care provider.
  • Put your full name and contact information in the body of your message. This will ensure your health care provider knows which client has sent the message.
  • Keep a copy of the e-mail or text messages you send and/or receive.


If required, call Dr. Pacheco and, if not available immediately, please leave a voice mail message with your name, telephone number, and a brief description of the situation.  Your call will be answered as soon as possible.

In the event of an emergency, call 911, or go to the nearest Hospital Emergency Room, where you will be assisted.


By signing this form, I confirm that:

  • I have had the opportunity to ask any questions about the preceding information;
  • I consent to the use of e-mail and/or text messages;
  • I consent to the use of e-mail and/or text messages for matters relating to scheduling, changing, and/or cancelling appointments;
  • I will follow the guidelines listed above;
  • I agree to accept, as outlined above, e-mail and/or text messages from Dr. Pacheco, his Assistants, and/or Associates;
  • I accept full responsibility for such communications;
  • I acknowledge receipt of a copy of this document, of the Privacy and Confidentiality Policy Summary, and of the Privacy Policy; and,
  • In addition, for the sending/receiving of Professional Service Statements and matters thereof, my(our) preference is [Check/Complete Only One]:

0 E-Mail: __________________________________________________________________________________________________________

0 Fax:  ____________________________________________________________________________________________________________

0 Postal Service:  __________________________________________________________________________________________________

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