Patient Information Template (Page 8 of 8) in pdf

Patient Information Template Page 8

Gwinnett OB/Gyn Associates, P.C.

1700 Tree Lane Road

Suite 290

Snellville, GA 30078

PATIENT’S CONFIDENTIALITY INSTRUCTIONS

Patient Name __________________________________ Acct# __________

It is important for us to honor the confidentiality between patient and physician.

PLEASE CHECK YOUR PREFERENCE BELOW.

_________ You may discuss my medical information ONLY with me.

_________ I give my permission to discuss my medical information with the following people:

_____________________________________ Relationship _________________

_____________________________________ Relationship __________________

YES or NO You may leave medical information ( test results) on my voice mail at:

(circle one)

Cell # _________________________

Home # ________________________

Signed ___________________________________Date ______________

Patient Information Template Page 8