Appointment Reminder Consent Form

Patient Name

Date of Birth

Date

Please select one or both of the following. If neither are selected, reminders will default to a phone call.

Text Message Email

Primary phone number (Please list only one number for text reminders):

Please enter a valid phone number.

This phone number belongs to:

Email address (Please list only one email address for email reminders):

example@example.com

This email address belongs to:

I understand that message/data rates may apply to messages sent by Integrative Psychiatry under my cell phone plan. I know that I am under no obligation to authorize Integrative Psychiatry to send me text messages and/or emails. I may opt out of receiving these communications at any time by calling the office at (402) 933-5700.

I understand that email and text reminders are auto-generated by Integrative Psychiatry's Electronic Health Record system as a courtesy, and are not a way to change or modify appointments. If I need to speak to someone regarding my appointment, I will call the office directly at (402)933-5700. I understand that I will be charged for any missed appointments or visits cancelled with less than 24 hours' notice, as outlined in the policies of Integrative Psychiatry.

I understand that text messaging and email are not secure formats of communication. There is some risk that individually identifiable health information or other sensitive information contained in such text may be misdirected, disclosed to, or intercepted by unauthorized third parties. Information included in text messages/emails may include your first name, date/time of appointments, name of physician, or other pertinent information.

By signing below, I accept the risk explained above and consent to receive text messages and/or emails via automated technology from Integrative Psychiatry and its affiliates.

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Date

Printed name

Relationship to Patient