Consent for Appointment Reminders via Text-Messaging

SouthPointe Plaza

1901 E 32nd St Ste 20

Joplin MO

(417) 781-2046

www.apclinic.net
Consent for Appointment Reminders via Text-Messaging
Date*

MonthDayYear
Date
Patient Name*

First NameMiddle NameLast Name
Patient Birth Date*

MonthDayYear
Cell Phone Number*

Area CodePhone Number
I consent to receive text messages from the practice on my cell phone for appointment reminders. I understand this request to receive text messages will apply to all future appointment reminders. I can opt-out of text messaging at any time by replying STOP to any text I receive.
This practice does not charge for this service, but standard text messaging rates apply as provided in your wireless plan (contact your carrier for pricing plans and details of your plan)
Patient Signature*

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Patient Signature
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