Text & Email Consent Form

TEXT MESSAGES

We are providing a text message service to our patients! Each patient with a scheduled appointment will receive text messages on their cell phones reminding them of the appointment.

This is a free service from us but text message rates from your cell phone carrier may apply

YES, I want to receive text messages to remind me of my dental appointments NO, I do not want to receive text messages to remind me of my dental appointments

Cell Phone Number

E-MAIL MESSAGES

We are providing an e-mail message service to our patients! Each patient with a scheduled appointment will receive an email messages reminding them of the appointment.

YES, I want to receive e-mail messages to remind me of my dental appointments NO, I do not want to receive e-mail messages to remind me of my dental appointments

Email address

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

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