California Clinic for Anxiety Disorders, P.S. Annie Zadori, Psy.D License number: PSY32733 Patient Name: First AUTHORIZATION TO IDENTIFY SELF BY LEAVING VOICEMAIL, TEXT MESSAGE, OR HOUSHOLD MEMBER OR OTHER PROFESSIONAL IDENTIFIED BELOWIt is sometimes necessary for your treating doctor or their representatives to leave a message for patients. The purpose of these messages is to remind patients of their appointments and/or to reschedule appointments, or to ask patient to call the office regarding an issue or concern. The office representative or the therapist will not be discussing clinical or other medical concerns via messages without your consent. I authorize Dr. Zadori or the treating Registered Psychological Assistant to identify themselves as calling from the doctor’s office and leave messages with any person answering the phone, on voice mail, or via text messaging.1. Home Telephone: 2. Cell Phone: 3. Work Telephone: This consent will be in effect for as long as I remain a patient of Annie Zadori, Psy.D.PATIENT SIGNATURE:DATE: MM slash DD slash YYYY CONFIDENTIALITY NOTICEThe documents including and/or accompanying this telecopy transmission contain confidential information belonging to the sender that is legally privileged. This information is intended only for the use of individual or entity named above. The authorized recipient of this information is prohibited from disclosing this information to any other party and is required to destroy the information after its stated need has been fulfilled, unless otherwise required by state law. If you are not the intended recipient you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this telecopy in error, please notify the sender immediately to arrange for return of these documents.