Patient Communication Note

PATIENT COMMUNICATION NOTE
PATIENT NAME PATIENT NAME First Last
DATE OF COMMUNICATION DATE OF COMMUNICATION / MM / DD YYYY
Time Time : HH MM AM/PM
Appointment Phone Call Visit Other Other
COMMUNICATION WITH COMMUNICATION WITH First Last
NOTE
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ELECTRONIC SIGNATURE
By selecting the "SUBMIT" button, you are signing this Agreement electronically. You agree your electronic signature (hereafter referred to as your "E-Signature") is the legal equivalent of your manual/handwritten signature on this Agreement.

By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature.

Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature.
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I UNDERSTAND THAT CHECKING THIS BOX CONSTITUTES A LEGAL SIGNATURE CONFIRMING THAT I ACKNOWLEDGE AND AGREE TO THE ABOVE TERMS OF ACCEPTANCE.
DATE OF SIGNATURE DATE OF SIGNATURE / MM / DD YYYY
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Patient Communication Note

Patient Communication Note

PATIENT COMMUNICATION NOTE

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