Tricity Family Medicine & Urgent Care Clinic, PLLC

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

1106 Parkside Main Street, Cary NC 27519
PH: 919-261-6446 Fax: 919-261-6448

Permission for verbal communication form

PATIENT NAME

DATE OF BIRTH

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.

PATIENT'S SIGNATURE

DATE (MM/DD/YYYY)

Dr. Chaitany Patel, MD

Tricity Family Medicine & Urgent Care Clinic, PLLC

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

1106 Parkside Main Street, Cary NC 27519PH: 919-261-6446 Fax: 919-261-6448

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

1106 Parkside Main Street, Cary NC 27519
PH: 919-261-6446 Fax: 919-261-6448