Welch Pasteur Allergy Medical Group, Inc

Anita Carmen Choy, MD. |. Hailen Mak, MD
211 Quarry Road, Suite 106 MC 5996,
Palo Alto, CA 94304
Ph: 650.322.3847  |  Fax: 650.322.3249

Authorisation for Release of Protected Health Information 

I hereby give consent to Welch Pasteur Medical Allergy Group, Inc, its physicians and staff to communicate with me via e-mail and agree that:

• I will use e-mail for non-emergency purposes only;
• I have received a copy of this office's e-mail policies and have had a chance to ask questions about them;
• I understand that e-mail communications from my physician are not encrypted and that the security of such e-mails cannot be guaranteed;
• I understand that all e-mail communications will be filed in my permanent medical record; and - I agree to inform this office in writing if my e-mail address changes.