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Healthcare Seeker
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Consent
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*so that we can let you know when the referral has been completed
I have spoken to the patient/client above and they have agreed for me to fill out this form on their behalf. Patient/client and I both understand that this is only for purposes of communication with ICAN!, myself and the selected health center. Text/Emails are sent to make sure the patient/client can get their contraception of choice without barriers.
Referral Consent
Formulario Healthcare Seeker
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Consentimiento
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*para que recibas confirmaciĂ³n cuando esta informaciĂ³n sea compartida
He hablado con el paciente/cliente mencionado y ha aceptado que complete este formulario en su nombre. El paciente/cliente y yo entendemos que esto es solo para medios de comunicaciĂ³n con ICAN!, conmigo y con el centro de salud seleccionado. Se envĂ­an mensajes de texto/correos electrĂ³nicos para garantizar que el paciente/cliente pueda obtener el mĂ©todo anticonceptivo de su elecciĂ³n sin barreras.
Consentimiento para compartir