BONNIE J. BALDWIN

Consultants in Plastic Surgery

P. A

AESTHETIC AND RECONSTRUCTIVE PLASTIC SURGERY

7700 San Felipe, Suite #275

Patient Consent for Use of Email Communications

To better serve our patients, this office has established an email address for some forms of

communication. For routine matters that do not require immediate response, please feel free to

info@bonniebaldwinmd.com

Please remember however, that this form of

communication is not appropriate for use in an emergency. The turnaround time for routine

patient communication is 24 hours. The service provider may delay message delivery.

Should

you require urgent or immediate attention, this medium is not appropriate.

When sending an email, please put the subject of your message in the subject line so we can

process it more efficiently. Also, be sure to put your name and return telephone number in the

body of the message. We also ask that you acknowledge receipt of emails coming from this office

by using the auto reply feature.

Communications relating to diagnosis & treatment will be filed in your medical record.

This office is dedicated to keeping your medical record information confidential. Despite our best

efforts, due to nature of email, third parties may have access to messages.

When communicating

from work, you should be aware that some companies consider email corporate property and

your messages may be monitored. Even when emailing from home, you may feel that access to

our email is not controlled, so you should take that into consideration. In addition, you should be

aware that, although addressed to me, my staff, and/or colleagues would have access to this

information.

I understand that this office will not be responsible for information loss or delay or breaches in

confidentiality that are due to technical factors beyond this office’s control.

I understand and agree to the above email policy.

By signing below, you are agreeing that we may send medical related correspondence to you via

email, and that we may respond to your emails to us via email.

_____________________________

Patient Signature

Witness (Optional)

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Date