Back
CONSENT SMS SERVICES
First Name
Last Name
Date Of Birth
Please read carefully and sign the necessary authorizations, releases, and agreements.
CONSENT TO TEXT MESSAGES:
[Company Name] may contact you via SMS service with information related to appointment reminders, electronic forms and reviews.
You can cancel the SMS service at any time. Reply STOP to opt out. After you send the SMS message "STOP" to us, we will send you an SMS message to confirm that you have been unsubscribed. After this, you will no longer receive SMS messages from us. If you want to join again, just sign up as you did the first time, and we will start sending SMS messages to you again.
If you are experiencing issues with the messaging program you can reply with the keyword HELP for more assistance, or you can get help directly at [phone number or email].
Carriers are not liable for delayed or undelivered messages
Message frequency varies.
As always, message and data rates may apply for any messages sent to you from us and to us from you. If you have any questions about your text plan or data plan, it is best to contact your wireless provider.
PRIVACY POLICY &. TERMS
Text messaging originator opt-in data and consent will not be shared with any third parties, excluding aggregators and providers of the Text Message services.
For your convenience our office can communicate with you by
text
. It's okay for the office to:
Phone Number
Patient/Legal Guardian Signature
Sign Here
×
Signature Pad
Date
Back
Next
Back
Next
Submit
Done