You may be contacted by this office to remind you of any appointments, healthcare treatment
options or other health services that may be of interest to you.

May we contact you at home? Y/N Tel. (__)_______ OK to leave Voice mail Y/N
May we contact you at work? Y/N Tel. (__)_______ OK to leave Voice Mail Y/N
May we contact you via cell phone? Y/N Tel. (__)_______ OK to leave Voice mail Y/N

Comment:________________________________________________

Can a message be left with our company name and what the call is in reference to? Yes / No
Is there anyone we can leave a message with? Yes / No (if yes, please list first and last names)

________________________________________________

________________________________________________

Would you like to authorize an individual as your personal representative? This person would have
the authority to schedule, confirm or change appointments only. Yes / No (if yes, please list first and last
names)

Patient Signature_____________________________________Date______________________

Gulf Coast Facial Plastics and ENT Center has provided me with a copy of my rights as a patient under the HIPAA act. I have been provided the opportunity to read and understand my rights and ask questions regarding my rights and receive answers to my satisfaction.

Patient Signature_____________________________________Date______________________