Patient E-mail and Text Messaging Consent Form
Patient Name:_____________________________________Date of Birth:__________________
Due to the changing world of health care and technology, we now have the ability to provide our patients with certain types of information via e-mail and/or text messaging. If you wish to have the opportunity to receive information of this type, please complete the form below.
Yes, please sign me up to receive e-mail and text messaging confirmations.
I do not wish to be contacted via email. (Text messaging only)
I do not wish to be contacted via text messaging. (E-mail only)
I do not wish to be contacted by either text messaging or email.
I am aware that there is some level of risk that third parties might be able to read unencrypted emails and/or text messages.
I am responsible for providing the dental practice any updates to my email address or cell phone.
I can withdraw my consent to electronic communications by calling: 252-504-2138
Patient E-mail Address:__________________________________________________________
Patient Cell Phone: _____________________________________________________________
Patient Signature:_________________________________________ Date:_________________