• Electronic Communication Consent Form

  • I consent that the Company can provide their services and communicate with me via mobile phone, messages, e-mail and any kind of online communications, provided that these comminications comply with privacy regulations.

     

    Appointment Reminders, Reschedules and Cancellations

    I understand that Company can reach me any time to remind me of my appointments or let me know in case of any change about my appointments. And I also understand that the Company can employ and use a third-party automated system to reach out me for the purpose of "confirm", "reschedule" or "cancel".

     

    Telemedicine Appointments

    For telemedicine, I understand the appointments will be held via electronic environments.

     

    Contact Information Change

    I accept that I am responsible of notifying the Company when my contact informations change.

     

    Consent Cancellations

    I know that I can revoke this consent at any time by contacting the Company. 

     

  • I consent to the use of mobile phone communications.
  • I consent to the use of texting (messages) communications.
  • I consent to receive electronic notifications for confirming, rescheduling or cancelling my appointments.
  • I sign this consent form on the behalf of
  • Date of Sign
     - -
  • Clear
  • Should be Empty:
Select theme:
  • Default
  • Blue
  • Red
  • Brown
  • Green
  • Black
  • Pink
  • Dark Blue
  • Purple