REQUEST TO USE E-MAIL FOR HEALTH CARE INFORMATION

I hereby request, and consent to,the provision by Helena HealthCare, Inc., of health care information (including laboratory and other test results) about me by the use of e-mail addressed to the e-mail address listed below.

I also request, and consent to the provision of health care information by e-mail for the following dependents.

Name                                            Legal Guardian                        SSN                       Residence

_________________________ _____________________ _____________ _____________

_________________________ ______________________ _____________ _____________

_________________________ ______________________ _____________ _____________

I acknowledge that the use of e-mail and the Internet is not technologically secure, that third parties may have the ability to access my e-mail and the health care information included in an e-mail, and that other persons (friends and family members) may have the opportunity to access e-mail messages addressed to me at my e-mail address below.

I understand that a permanent record, either electronic or on paper, will be made of all correspondence.

I, for myself, my heirs, personal representatives, and assigns, hereby waive any and all claims for damages that I may have, or that may hereafter accrue to me, my heirs, personal representatives or assigns, as a result of the provision of health care information to me by e-mail sent to the e-mail address I have provided below.

I further discharge and release in advance Helena HealthCare, Inc., its directors, officers, employees, agents and representatives from any and all liability arising out of or connected in any way with the inadvertent disclosure of health care information about me to third persons resulting from sending health care information to me at the e-mail address I have provided below.

Full Name:                                    SSN:                                  Email Address:

_________________________ ___________________ _____________________________

Address:                                        City                                         State                    Zip

_________________________ _______________________ ____________ __________

This email address is shared with_______________________________________________________

Preferred Login ID: _____________          Suggested Password: _________________

Dated:  ______________________          Patient Signature:  _______________________________