Communication Consent Form

Thank you for interest in an eye exam with Cornerstone Family Eyecare. You will be redirected to our online appointment portal after completing the communication consent form.

This SMS consent information will NOT be used for the purpose of selling or sharing SMS opt-in phone numbers but communication only with our office and potential patients only. You can opt out at anytime by texting STOP.

You can review our SMS policy and terms of use by clicking here.

Patient Name*

First NameLast Name

Contact Number*

Please enter a valid phone number.

Email Address

example@example.com

Thank you for your interest in an eye exam at Cornerstone Family Eyecare. Please opt-in or opt-out of receiving SMS or Text communication from our office regarding your office visit.*

Yes, I agree to receiving communication text messages as needed for my appointment from Cornerstone Family Eyecare. I understand messages frequency may vary. Message data rates may apply. You can opt out any time by texting STOP.No, I DO NOT agree to receiving communication through text message from Cornerston

By continuing booking, I declare that I, as the person booking, am 18 years or older, am authorized to book on behalf of any person listed in this form. I understanding I can always review our SMS and terms of use policy here: The Optometry Practice SMS Terms & Conditions and Privacy Policy.

Please verify that you are human*