Communication Consent Form

Preferred Communication Methods

Acknowledgment and Consent

By signing below, I understand and agree to the following:

• I give permission to Dr. David M. Seidman and staff to contact me using the selected methods.
• I understand that text and email are not secure and may expose PHI to unauthorized access.
• Reasonable safeguards are in place, but the practice cannot guarantee total security.
• I may revoke this consent in writing at any time.
• This consent remains in effect unless revoked in writing.

Patient Contact Information