Communication Agreement. (1) The Company may accept from cardholders (hereinafter referred to as "members"), of credit card companies (hereinafter referred to as "Affiliated Companies") provided by the Company payment for travel expenses via "telephone, mail, facsimile and other communication methods" (hereinafter referred to as "communication contract"). Only payments of the full amount of the travel expenses shall be accepted for these payment methods. However, such payment methods may not be accepted if the Company has no franchise agreement, including signed special agreements with the partner company or for some business reasons. (Depending on the contracting travel agency, such payments may not be available to the customer. And, the type of credit cards with which such payment is available may differ depending on the contracting travel agency. Agreements mentioning specific vouchers to be signed by the customer and payments via credit card are not regarded as communication agreements, but as usual travel agreements.)
Communication Agreement. I agree to make communication between myself and the Instructors of the Studios as open as possible by providing an e-mail address I know to be current and accessible. Furthermore, I agree to check that e-mail frequently so that I may see any updates from my (or my child’s) Instructor or the Director.
Communication Agreement. It is the policy of Adirondack Direct Primary Care, PLLC not to release confidential and/or unauthorized information by any means. Whenever returning telephone calls and the answering machine picks up, we do not leave a message if the name or telephone number is not on the recorded message to identify the residence. Also, the information beyond our identification and return contact numbers will not be left with an answering machine.
Communication Agreement. I am happy for the school to send me publications (i.e. the school newsletter) via the school’s text/email system. I am happy for the school to send me regulated third party marketing, deemed suitable by the school. These would include our FISA (PTA) newsletters and external clubs information via the school’s text/email system. OFFSITE CONSENT: I understand that if my child requires medical/dental treatment during the school day or during an out of school activity and it is not possible to contact any parent or guardian, the teacher-in-charge at the time is authorised to give consent to medical professionals on my behalf. I give permission for my child to leave the school premises for local visits and at other times when I am informed separately by letter (or on occasion, as requested by phone). ONLINE CONSENT: I can confirm that both myself and my child have read the Online Consent agreements and agree to follow these rules in and out of school. My child understands that if he/she breaks any of the Online Safety rules, any usernames or passwords will be blocked. The teacher in charge of computing will decide how long he/she will be blocked for or if they should be blocked permanently.
Communication Agreement. This policy is intended for patients that have a password-protected email and is checked at least 2-3 times per week. CVFC will only communicate electronically with the approved email address you have provided. CVFC can be contacted via email through our website at xxx.XXXxxxxxXxxx.xxx. When requesting information please include your full name and birth date in the message to establish reasonableness that the sender requesting information is who the sender claims to be. The subject of the email should include the provider’s name and the purpose of the email. This office will use the provided email address to communicate directly with you. It will not be released to any third party other than for use of treatment, payment and healthcare operations. CVFC cannot and does not guarantee the privacy or security of any message sent over the internet. There is the potential that an email sent over the internet can by intercepted and read by others. I have read the above items regarding insurance and financial responsibility, consent and medical records and e- communication and agree to the terms and conditions related to each item. Patient or Responsible Party Signature Date Patient Medical, Surgical, Social & Family History Date: Medical History Name : Date of Birth: Medication Allergies: List all Current Medications (prescriptions, OTC, or herbal remedies) Pharmacy: ❑ Watertown Drug ❑ Xxxx (Alexandria) Lebanon Pharmacies: ❑ Buckeye ❑ CVS ❑ Xxxx’s ❑ Xxxxx ❑ Kmart ❑ Kroger ❑ Publix ❑ Rite Aid ❑ Walgreens (S. Cumberland) ❑ Walgreens (W. Main) ❑ Walmart ❑ Other w/ phone number: Patient Health History ❑ No History of Illness ❑ ADHD ❑ Hearing Loss Health Maintenance: ❑ Allergies (Seasonal) ❑ Heart Attack Date of Last Complete Physical: ❑ Arthritis ❑ Heart Burn (acid reflux) ❑ Asthma ❑ High Blood Pressure Date of Last Bone Density: ❑ Bipolar ❑ High Cholesterol ❑ Cancer (location: ) ❑ Hypothyroid Date of Last Colonoscopy: ❑ Congestive Heart Failure ❑ Interstitial Cystitis ❑ COPD / Emphysema ❑ Kidney Stones Date of Last Tetanus Immunization: ❑ Crohn’s ❑ Mental Retardation ❑ Depression / Anxiety ❑ Migraine Headaches Women Only: ❑ Diabetes ❑ Seizures Date of last Mammogram: ❑ Diverticulitis ❑ Stomach Ulcers ❑ Fibromyalgia ❑ Stroke Date of last Pap: ❑ Gout ❑ Other:
Communication Agreement. The student must contact the instructor times per week during the directed study time period. Students are encouraged to do so by email; other options include office appointments, phone calls, or other means deemed appropriate.
