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Neuropathy & Neurotherapy Center of Dallas
12870 Hillcrest Road, Suite H201, Dallas, Texas, 75230
P: (972) 9911153 F: (972) 991-1346
Patient Name:
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Date of Birth:
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Patient Preference Regarding Communication of Health Information
I.
WHO TO CONTACT:
I hereby give permission to Neuropathy Center of Dallas to disclose and discuss any information related to my medical condition(s) to/with the following family member(s), other relative(s), and/or personal friend(s):
Name:
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Relationship:
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Name:
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Relationship:
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Name:
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Relationship:
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I do NOT wish to give permission for additional family members, relatives, or close personal friends to have any access to any information regarding my medical condition(s)
II.
HOW TO CONTACT
I wish to be contacted in this following manner:
HOME/CELL PHONE:
*
OK to leave a message with detailed information
Leave a message with call-back number only
WORK PHONE:
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OK to leave a message with detailed information
Leave a message with call-back number only
PATIENT SIGNATURE:
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DATE:
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