Mr Nigel G Taylor

MDSc, BDS, FDS RCS(Ed), FDS RCS(Eng), M’Orth RCS(Ed), D’Orth RCS(Eng), FDTFed RCS(Ed)

 

 

Consent Form for E-mail and Text

 

Brockley House Orthodontics on occasions contacts patients or a healthcare provider by email or text; however, increasing numbers of patients are using electronic means of communication which require an electronic response. To comply with best practice please complete and return this form.

 

Email is inherently unsecure unless it is fully encrypted requiring the use of strong authentication and password protection. Most email does not meet those standards. Among the many risks of using email or text to communicate information:

 

  • Email and texts can be forwarded, printed, and stored in numerous paper and electronic forms and be received by many intended and unintended recipients without knowledge or agreement.
  • Emails and texts may be sent to the wrong address by any sender or receiver.
  • Emails and texts are easier to forge than handwritten or signed papers.
  • Copies of emails and texts may exist even after the sender or the receiver has deleted his or her copy.
  • Email service providers have a right to archive and inspect emails sent through their systems.
  • Email can be intercepted, altered, forwarded, or used without detection or authorization.
  • Email can spread computer viruses.
  • Emails and texts delivery is not guaranteed.
  • Email can be used for Phishing. Phishing is a technique of obtaining sensitive personal information from individuals by pretending to be a trusted sender.
  • The use of open internet email channels is not secure or encrypted – meaning that messages between could potentially be viewed by unauthorized persons who might intercept or read those emails.
  • Emails and texts may or may not be received or read.
  • Emails and texts are not an appropriate method for sharing urgent or emergent information.
  • Brockley House Orthodontics will never ask for personal identifying information or other sensitive information using open email. Such information might include date of birth, mother’s maiden name, social security numbers, or other personal identifying information.

I consent to and accept the risk in communicating information via email 

My email address is …………………………………………………………………………….

      

I consentto and accept the risk in communicating information via texts. . 

My mobile telephone number is ………………………………………………………………....

 

I understand that I can withdraw consent at any time.

I do not consentto any information being transmitted via email

I do not consentto any information being transmitted via text

I understand that I can change my mind and provide consent later.

Patient’s Name …………………………………………..                     

Date of birth ……………….

Signature …………………………………………………                      

Date ……………………….

 

Printed name …………………………………………


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