Patient Email and Text Message Consent Form

NJ Green MD Evaluation and Registration Services would like to communicate with you by E-mail
and Text message (SMS) to provide general business information such as appointment reminders,
updates on registrations in process, provide links to access secure web form submissions,
correspondence regarding billing, weather related closings, special holiday hours or office hour
changes, location announcements, sales and promotions. This form provides information about the
risks of these forms of communication, guidelines for email/text communication, and how we use
email/text communication. It also will be used to document your consent for communication with you
be email and text message (SMS).
How we will use email and text messaging: NJ Green MD will use these methods to communicate
general business information such as appointment reminders, updates on registrations in process,
provide links to access secure web form submissions, correspondence regarding billing, weather related
closings, special holiday hours or office hour changes, location announcements, sales and promotions.
If you choose to respond by email or text message, NJ Green MD is not responsible for the security of
those responses and may forward them to another NJ Green MD staff member as necessary for
appropriate handling.
Risk of using Email Or Text Messages: The use of email and text messages has a number of risks that
you should consider. These risks include, but are not limited to the following:
1. Emails and texts can be circulated, forwarded, stored electronically and on paper, and
broadcast to unintended recipients.
2. Backup copies of emails and texts may exist even after the sender/ and or recipient has
deleted his or her copy.
3. Employers and on-line services have a right to inspect emails and texts sent through
their company systems.
4. Emails and texts can be intercepted, altered, forwarded or used without authorization or
detection.
5. Emails and texts may be used as evidence in court.
6. Email and text messaging may not be secure, and therefore it is possible that a third
party may breach the confidentiality of such communications.
Conditions for the use of emails and text messages: NJ Green MD cannot guarantee but will
use reasonable means to maintain security and confidentiality of email/text information sent and
received. You must acknowledge and consent to the following conditions.
1. IN A EMERGENCY DO NOT USE EMAIL OR TEXT MESSAGING, CALL 911.
Do not email or text for urgent problems
2. Email and text messages may be filed electronically into your patient record
3. NJ Green MD employees will not forward your identifiable email/texts to outside parties
without your written consent, except as authorized by law
4. You should use your best judgment when considering the use of email or text messages for
communication of sensitive medical information. NJ Green MD employees are not responsible
for the content of the messages sent by patients.
5.NJ Green MD is not liable for the breaches of confidentiality caused by you or any third party.
Withdraw of consent: I understand that I may revoke this consent at any time by advising NJ Green
MD in writing. Patients may also follow the appropriate protocols in emails and texts to “unsubscribe”
from receiving notifications.
Patient Acknowledgment and Agreement: I acknowledge that I have read and fully understand the
consent form of communication between NJ Green MD and me, and consent to the conditions and
instructions outlined, as well as any other instruction NJ Green MD may impose to communicate with
me by email or text message.