I, hereby request Demo Healthcare, PA to keep communications regarding my protected health information confidential. To accomplish this request please adhere to the following requests:
Our preferred method of communication is through our secure patient portal.Providing your email address allows us to invite you to join our portal.
Preferred Contact Format:
I give authorization to the doctors and staff of Demo Healthcare to discuss any of my medical and/or financial information with the following people:
Contact Name 1
Contact Name 2
Contact Name 3
Patient Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.