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Mail to:  Kern Valley Healthcare District
Patient Accounting Department
P.O. Box 1628
Lake Isabella, CA 93240

Patient Name: ________________________________________

MRN: _________________  Date of Birth __________________

                                                    Your Acknowledgment and Agreement

                    I acknowledge that I have read and fully understand the E-Mail Disclaimer.

                    I understand the risks associated with the communication of e-mail between KVHD and me, and consent to the conditions outlined in the Disclaimer. In addition, I agree to the instructions outlined in the disclaimer, as well as any other instructions that KVHD may impose to communicate with patients by e-mail.

                    Patient’s signature________________________________________

                    E-mail address________________________________________ (Please print)

                    Date_________________________

                    Witness signature_________________________________________

                    Date_________________________