A Woman's Choice, Inc.

Patient Contact Information Form

Patient Contact Information

Name *
Name
Date *
Date
Address *
Address
Phone *
Phone
Alt Phone
Alt Phone
Preferred Contact Method *
Federal privacy rules require that you tell us how to contact you with information, lab results, appointment changes, and other information that is crucial to your care with us. Please check all that apply:
Custom email or text message (if selected):
*
The best way to mail information to me:
I UNDERSTAND STAFF MAY PERIODICALLY NEED TO CONTACT ME WITH TEST RESULTS OR OTHER INFORMATION ABOUT MY CARE WITH AWC. AWC HAS MADE MY PREFERENCES KNOWN ABOUT HOW TO CONTACT ME. I ALSO UNDERSTAND THAT CRITICAL SITUATIONS MAY ARISE THAT REQUIRE AWC TO CONTACT ME QUICKLY. IF UNABLE TO DO SO, I UNDERSTAND THAT AWC MAY SEND CERTIFIED MAIL TO MY HOME ADDRESS AS A WAY TO MAKE DIRECT CONTACT WITH ME. BY SIGNING BELOW, I AGREE TO A WOMAN’S CHOICE CONTACT PROCEDURES. *
I UNDERSTAND STAFF MAY PERIODICALLY NEED TO CONTACT ME WITH TEST RESULTS OR OTHER INFORMATION ABOUT MY CARE WITH AWC. AWC HAS MADE MY PREFERENCES KNOWN ABOUT HOW TO CONTACT ME. I ALSO UNDERSTAND THAT CRITICAL SITUATIONS MAY ARISE THAT REQUIRE AWC TO CONTACT ME QUICKLY. IF UNABLE TO DO SO, I UNDERSTAND THAT AWC MAY SEND CERTIFIED MAIL TO MY HOME ADDRESS AS A WAY TO MAKE DIRECT CONTACT WITH ME. BY SIGNING BELOW, I AGREE TO A WOMAN’S CHOICE CONTACT PROCEDURES.