Patient Text Message Consent Form
Authorize your healthcare provider or clinic to send you text message communications. Please complete the following fields to provide your consent.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Mobile Phone Number (for text messages)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Language for Communication
*
Please Select
English
Spanish
Other
Types of Text Messages You Agree to Receive
*
Appointment Reminders
General Health Information
Clinic Announcements
Best Time to Receive Text Messages
Please Select
Morning (8am–12pm)
Afternoon (12pm–5pm)
Evening (5pm–8pm)
Anytime
Signature
*
Today's Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Consent
Submit Consent
Should be Empty: