TEXT/SMS COMMUNICATIONS CONSENT FORM

TEXT/SMS COMMUNICATIONS CONSENT FORM

Text Messaging / Emails and Online Access Consent / Decline Form
Jackson-Bibby Awareness Group Inc. can now communicate with patients using simple message service (SMS) text messages and emails. These can be received with an appropriate device i.e. smart phone or tablet and can include appointment reminders and general class information.

These services should not be solely relied upon, the responsibility of attending appointments or cancelling them still rests with you. You can cancel these services at any time.

The messages are generated using a secure system however, they are transmitted over public networks to a personal device and as such are not secure. The practice will not transmit any information that would enable an individual client to be identified without prior consent.

Please tick the appropriate box below
I *CONSENT / DECLINE (delete as appropriate) to the practice contacting me by text/email for the purposes of class information and appointment reminders.

Text/EmailText ONLYEmail ONLY
Please provide your current contact details
Patient Name*
Signature*

Clear
Date*

MonthDayYear
Date
Mobile Number To Be Used
Please enter a valid phone number.
Home Telephone Number
Please enter a valid phone number.
Email Address To Be Used*
example@example.com
Date Of Birth*

MonthDayYear
Date
I also agree to advise the Jackson-Bibby Awareness Group Inc. if my mobile number or email address changes to keep my records up to date.
Location*
Driver License/Photo Id

Cancelof
On submitting the form, the form(s) will be emailed directly to Jackson-Bibby.
Should be Empty: