APPOINTMENTS:
972-548-7888

3701 Eldorado Parkway
McKinney, TX 75070
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PHONE MESSAGE CONSENT FORM
 
Your physician(s) and other staff members will, at times, need to contact you. By filling out the information below, we will be better able to serve you.

UNLESS WE HAVE YOUR WRITTEN PERMISSION TO DO SO, WE WILL NOT:
  • LEAVE MESSAGES WITH ANYONE EXCEPT THE PATIENT OR LEGAL GUARDIAN.
  • LEAVE INFORMATION ON AN ANSWERING MACHINE
  • LEAVE INFORMATION ON A VOICE MAIL
  • RECEIVE TEXT MESSAGES
Please read below and consider carefully whom you want to have access to your child’s medical information.

I give Pediatric Healthcare Associates, PA my permission to leave detailed phone messages regarding my child’s medical care and test results with the following individual(s) and/or answering systems.

 
         
     
         
 
         
     

By signing this form, I am agreeing to the above medical release. I understand that this agreement will be in effect until I revoke it in writing.

  Patient DOB:
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  Date:
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3701 Eldorado Parkway, Suite A, McKinney, TX 75070 972-548-7888 www.phamckinney.com

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