Consent for SMS Text Communications
{Practice Name}
Patient name:
Date of birth:
Phone (mobile):
I authorize {Practice Name} to send me text messages relating to my care, including telehealth visit links, appointment reminders, and related communications.
Standard message and data rates may apply. Message frequency varies based on my appointments.
I understand SMS messages are not encrypted and are not protected by HIPAA in transit, and I accept this risk for the convenience of receiving care communications by text.
I understand I can opt out at any time by replying STOP to any message, or reply HELP for help.
For minors, the parent or guardian providing this consent confirms their authority to do so on behalf of the patient.
I consent to receive SMS text messages as described above.
Signature:
Date:
Printed name:
Relationship to patient (if guardian):