Patient Consent Form

Patient access to the SAMS Patient Portal is granted by signing and acknowledging the Terms of Use prior to accessing the service online. I, , request access to the SAMS Patient Portal. I have read the SAMS Patient Portal Terms of Use Agreement and other information provided to me regarding the SAMS Patient Portal. I acknowledge that I understand the following: My use of this service is voluntary, and I may withdraw from using this service at any time, which will not affect my patient status at SAMS. Other than for the purposes of administration of this service by the authorized personnel of SAMS, its affiliates and franchises, no other person will have access to my personal health information through the SAMS Patient Portal, except as permitted with my written consent. Clinical health information available through the SAMS Patient Portal is provided by SAMS at my request for my personal use only and may be subject to verification without notice. SAMS, its affiliates, and franchises assume no liability for the release of clinical health information to me and my use of it. Access to and use of the SAMS Patient Portal is subject to the SAMS Patient Portal Terms of Use and Agreement for this service, and I agree to be bound by the aforementioned agreement. I will receive a copy of this signed form. Patient Name * Patient Email * Patient Full Address *
(Street / City, State, Zip / Country) Patient Date of Birth * Daytime Phone Number Mobile Phone Number Date * Signature *

Patient Consent Form

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