TEXT MESSAGE TO MOBILE CONSENT FORM

TEXT MESSAGE TO MOBILE CONSENT FORM

PURPOSE: This form is used to obtain your consent to communicate with you by mobile text messaging regarding your Protected Health Information.  Santa Rosa Family Dentistry, offers patients the opportunity to communicate by mobile text messaging.  Transmitting patient information by mobile texting has a number of risks that patients should consider before granting consent to use mobile text messaging for these purposes.  Santa Rosa Family Dentistry cannot guarantee the security and confidentiality of mobile texting communication and will not be liable for inadvertent disclosure of confidential information. 

“I consent to receive SMS text messages from Santa Rosa Family Dentistry for appointment reminders, marketing messages, and general two-way communication. Message frequency varies. Message and data rates may apply.  Reply HELP for support.  Reply STOP to opt out. Refer to our (hyperlink to privacy policy) and (hyperlink to terms and conditions) for more information”

______ I consent and accept the risk in receiving information via mobile text messaging.

 

Patient’s Signature:                                                                                                             Date: