Consent to Use Email Communication
Please READ the risks of using email before giving your consent to communicating with Acton Medical and Urgent Care via email.
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Full Name as printed on your Health Card: *
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Health Card Number, including version code(2 letters following the number): *
Date of Birth *
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Primary Contact Number *
Email Address: *
EMAIL CONSENT FORM:  Please read the risks of using email before giving your consent:
EMAIL CONSENT FORM
Consent to Email Communications:     Provide your initials below if you give consent for Acton Medical and Urgent Care to use the email address you provided for email communications.  If you choose to decline the use of email for communication do not continue with submission of this form. *
Date:     Provide the date of consent below - if you have consented to email communication. *
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