Healthcare SMS Communication Request Form
Request SMS notifications from your healthcare provider and specify your communication preferences. Please complete all fields to ensure we deliver messages according to your needs.
Full Name
*
First Name
Last Name
Mobile Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Your Role
*
Please Select
Patient
Parent or Guardian
Caregiver
Other
Preferred Time(s) for SMS Communication
*
Morning (8am–12pm)
Afternoon (12pm–5pm)
Evening (5pm–8pm)
Anytime
Type of Information You Wish to Receive via SMS
*
Appointment Reminders
General Health Tips
Prescription Notifications
Clinic Updates
Other
Preferred SMS Frequency
*
As Needed (only important updates)
Weekly
Monthly
Preferred Language for SMS
*
Please Select
English
Spanish
French
Other
Relationship to Healthcare Provider
*
Current Patient
New Patient
Family Member
Other
Briefly describe your SMS communication request or needs
*
Additional Comments (optional)
Submit Request
Should be Empty: