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Pivotal Health > Forms > Electronic Communication Consent

Electronic Communication Consent

We have recently upgraded our computer software and as a result our SMS systems require your consent to be updated.

The purpose of this form is to seek your consent to the use and disclosure of your personal information (including health information) in regards to our reminders and notifications systems within our practice.

Prior to consenting we ask that you read the following document regarding electronic communication at Pivotal Health.

Pivotal Health Practice Communications with Patients

Pivotal Health Electronic Communication Consent

Please answer the following questions in regards to what health information you would like to receive electronically from Pivotal Health.
Do you consent to receive appointment reminders via SMS from Pivotal Health? i.e. notifications to you to remind you of upcoming appointment dates with the practice as well as allowing you to confirm your appointment*
Yes
No
Do you consent to receive clinical reminders via SMS from Pivotal Health? i.e. notifications to you to remind you to contact the practice to arrange appointments for regular clinical check-ups, medical procedures, immunisations due)*
Yes
No
Do you consent to receive clinical communications via SMS from Pivotal Health? i.e. communications to you about your clinical care at the practice such as returned pathology results or clinical messages from the medical practitioner*
Yes
No
Do you consent to receive health awareness communication via SMS from Pivotal Health? i.e. communications to you in relation to general health care information and health care services provided by this general practice including notification about changes to our clinic opening hours, and information about health care services provided by this general practice.*
Yes
No
My preferred contact for ALL communication with Pivotal Health is*
Phone (voice calls)
Letter
SMS
Email
Acknowledgement and Consent

I acknowledge and agree that, in the course of providing health care services to me, Pivotal Health may need to use and disclose my personal information (including any health information) as set out in this form.*
I agree
I confirm that, the information I have provided in this form reflects my wishes in regards to receiving communication from Pivotal Health*
I confirm
I confirm that, I have read the Pivotal Health Communication with Patients document provided at the beginning of this form*
I confirm
I consent to the information supplied to be updated in my medical record held by Pivotal Health*
I consent
I request that the following patients who are dependents of mine and are under 16 years of age have their record updated to reflect with the information I have provided above.
Consent given by*
First Last
Date of Birth*

Day
Month
Year

Mobile Phone Number
Email

Thank you
Thank you for completing this consent. We will update your records. Should you have any queries or concerns, please do not hesitate in contacting us on 07 3286 1122.

Call Now

Cnr Shore and Wynyard Streets
Cleveland QLD 4163

P: 07 3286 1122
F: 07 3286 1133

For After Hours Care
Phone Hello Home Doctor on 134 100 or
National Home Doctor Service 13 74 25 or 13 SICK

@ 2024 Pivotal health

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