HIPAA-Enabled Appointment Reminder Opt-In Form
Please complete this form to receive appointment reminders and related updates from our healthcare team. Your preferences will help us communicate with you effectively.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Preferred Communication Channel(s)
*
Text Message (SMS)
Phone Call
Email
Mobile Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Reminder Timing
*
1 day before appointment
2 days before appointment
Same day as appointment
Would you like to receive additional updates related to your appointments (e.g., rescheduling, cancellations)?
*
Yes
No
Submit
Should be Empty: