Consent to Text & Emails

CONSENT TO EMAIL OR TEXT USAGE
FOR APPOINTMENT REMINDERS AND OTHER HEALTHCARE COMMUNICATIONS
Patients in our practice may be contacted via email and/or text messaging to remind you of an appointment, to obtain feedback on your experience with our healthcare team, and to provide general health reminders/information.

If at any time I provide an email or text address at which I may be contacted, I consent to receive appointment reminders and other healthcare communications information at that email or text address from the Practice.
I consent to receive text messages from the practice on my cell phone and any number forwarded or transferred to that number or emails to receive communication as stated above. I understand that this request to receive emails and text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing. I authorize to receive text messages for appointment reminders, feedback, and general health reminders/information to the following Cell Phone number:
Your Phone
I authorize to receive email/text messages for appointment reminders and general health reminders/feedback/ information to the following Email Address:
Email*
Signature*
Your Name*
First Last

CONSENT TO EMAIL OR TEXT USAGE