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.

By completing the form below, you agree to the SMS Terms of Use for Cornerstone Family Eyecare and the patient. By continuing, 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.

Text communication is helpful to ensure your exam with Cornerstone Family Eyecare goes smoothly. We will limit the text messaging to information pertaining to your patient scheduling, copay related questions, or exam records request. Messages about your appointment will not be sent earlier than two weeks before your exam.

Please call 469-405-1779 for help to opt-in or out. 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. Text frequency may vary, and message data rates may apply. 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 Cornerstone Family Eyecare.

Privacy Policy and Communication Terms of Use

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