Appointment Reminders

Appointment Reminders
I full name give authorization for Heart and Solutions to send me text messages and or to call my phone number and leave a message to remind me of my counseling appointment. I understand that these reminders will only state the name of the provider, the date and time of your appointment and will not disclose the nature of your appointment. Reminders will be sent out through an automated system the day before a scheduled appointment. The appointment must be scheduled at least 48 hours in advance for reminders to be sent out. I understand that Heart and Solutions is not responsible for the confidentiality of the appointment reminder once it is distributed to your voicemail or to your mobile phone. I agree that I have authorization to request reminders to the telephone number listed below. I understand that it is my responsibility to inform Heart and Solutions if my telephone number changes and I would like to continue to receive reminders.
Client Name*

First NameLast Name
Client's Date of Birth*

MonthDayYear
Date
At this time our system is only able to send reminders via text OR phone call to a single phone number.
I would like to receive a reminder via

Phone CallText Message
You can choose to set up both a phone reminder AND email reminder at the same time.
I would like to receive an email reminder*

YesNo
Phone Number (if calling)
Phone Number (if texting)
Email address
Signature*

Clear
Date

MonthDayYear
Date
Name*

First NameLast Name
(ARCHIVED QUESTION) How would you like to be reminded?

Phone CallText messageEmail
Should be Empty: