Tricity Family Medicine & Urgent Care Clinic, PLLC

107 Hyannis Dr., Holly Spring, NC 27540
Ph: 919-363-8666   Fax: 919-363-8668

Permission for verbal communication form

I permit Tricity Family Medicine to discuss my health information, in person or by telephone, with the following family members or friends involved in my medical care: (List family members or friends & state relationship)

  Check here ONLY if you DO NOT want ANY health or billing information to be discussed with anyone other than yourself!!

If, at any time, I do not want verbal discussions to be permitted between my Health Care Provider and any of the individuals named above, I must notify my Health Care Provider.

Dr. Chaitany Patel, MD

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