Email Consent

New regulations and hospital policy require that anyone using email to communicate with health care providers understand and agree to a number of conditions and limitations. Stanford has created consent for this purpose. Please review this form and, if you agree with these conditions, please send a signed copy to

Medical Records, LPCH, 725 Welch Road,| Palo Alto, California 94304

Please includethe name and birthdate, as well as the Stanford Medical Record number if possible, of the patient this agreement applies to. Thank you.

If do NOT agree, please let us know and DON'T email any clinical information