Free Patient Communications Consent Agreement Template

The following legal agreement is available for public use at no charge, so long as the agreement is sourced back to Bridge, along with the following copyright information.


    1. This form describes the healthcare service provider’s (“Provider”) communication methods and includes:
      1. Your consent to the specified communication methods adopted by Provider
      2. Your agreement to be contacted at any time via a mobile device, phone call, SMS messages, e-mail and any other kind of communication specified by Provider, on the condition that these communications comply with privacy regulations.
    2. By electronically clicking “Agree” at the end of the Communications Consent Agreement, you explicitly accept the specified communication terms set forth below.


  1. You consent to the following communication methods:
    1. Appointment Reminders
    2. Clinical Reminders (e.g. Immunizations, Care Plans, Preventive Care)
    3. Clinical Communications (e.g. Results, Encounter Notes)
    4. Provider Business Changes (e.g. New Doctors, Location Changes, Fee Changes, Hours of Operation)
    5. New Patient-Provider Messages
    6. Prescription Refill Status
    7. Telehealth Visit Information
  2. You agree that Provider can reach you at any time via
    1. Patient Portal Secure Messaging
    2. Phone Call (incl. Automated IVR)
    3. Texting (SMS Messages) Communication
    4. Live Chat Communication
    5. Mobile Phone Communication
    6. E-Mail Communication
    7. Mail via Postal Service
  3. If your mobile number, as listed by Provider is utilized for more than one patient, you understand that all SMS communications as consented to above will be sent to that number.

  5. You further accept that you are responsible for notifying the Provider when your contact information changes.

  7. You can revoke this Communications Consent Agreement at any time by contacting the Provider.

Agreement template made available by Bridge Patient Portal LLC. Copyright © Bridge Patient Portal LLC. All rights reserved.

John Deutsch
John Deutsch

Chief Executive Officer (CEO) John is a seasoned executive with 20+ years of healthcare IT business ownership experience specializing in patient engagement, marketing, and software/web development. He was the co-founder of EMR Experts, an EHR consulting firm, which was sold to Bizmatics Inc in 2008. John then founded Medical Web Experts, a leader in custom HIPAA-compliant software/web development and marketing for the healthcare industry. Bridge Patient Portal, an all-in-one patient engagement solution, was spun off from Medical Web Experts in 2014. John split his time as CEO between both Medical Web Experts and Bridge Patient Portal until late 2019, at which point he stepped down as CEO at Medical Web Experts to focus solely on Bridge Patient Portal. Besides his extensive experience in business and workforce management, he also maintains strong technical knowledge in information systems, IT security, compliance, and healthcare.