Consent to Text Messages Please fill out and submit the form below. If you are human, leave this field blank. Consent to TEXT messages for Appointment Reminders: We want to stay connected with our patients. Patients in our practice may be contacted via call, text messaging or both to confirm an appointment, to obtain feedback on your experience with our healthcare team, and to be provided general health reminders. If at any time, you provide a cellular telephone number, you understand that you may get these communications from the Practice. You may opt out of these communications at any time. The practice does not charge for this service, but standard text messaging rates or cellular telephone minutes may apply as provided in your wireless plan. Name * Email * Accept or Decline Reminders * I Accept Reminders I Decline Reminders I authorize to receive TEXT messages for appointment reminders, the cell phone number is I authorize communication via ZOOM for business if a telehealth session is necessary. * Yes No A minimum of 24 HOURS NOTICE is STILL required for cancellation of appointments regardless of the presence or absence of a reminder call. If this notice is not received or the patient fails to show for the appointment, the responsible party will be charged the full missed appointment fee. Signature * Draw It Type It Clear
