New Patient Questionnaire

INTEGRAL HEALTH ASSOCIATES

I hereby consent to receive SMS (text) messages from Integral Health Associates for appointment reminders, scheduling changes, account notifications, and other similar information. I understand that texting may not be completely secure and that Integral Health Associates may opt to not communicate by text. I further understand that this consent in no way indicates that Integral Health Associates will utilize SMS texting as an appropriate or reliable means for me to communicate with them other than by responding to a text I receive with one of the provided response options. I have read and agree to the SMS Terms and Conditions. It is included in our online and mailed New Patient Packet, available on our website at www.integralhealthct.com, and copied below.

Signature of patient (or legal guardian if patient is under 18 years old) (Click on signature line):

Signature*

Name of patient*

First NameLast Name

Patient's date of birth:*

Date

Name of legal guardian if patient is under 18 years old

First NameLast Name

Signature of legal guardian if patient is under 18 years old (Click on signature line):

Signature

Date

SMS - Terms and Conditions
With your permission via an opt-in, we [Integral Health Associates] may communicate with you via SMS (texting) for non-clinical issues such as appointment reminders, weather-related closures, or account notifications. SMS is not considered fully secure. By opting in to SMS from a web-based form or other medium, you are agreeing to receive SMS messages from Integral Health Associates. Message frequency may vary, and message and data rates may apply. Per our privacy policy (http://www.integralhealthct.com/nopp), we do not sell or give out your opt-in status. Once opted-in, you may reply STOP to any message to opt out, or message HELP for help regarding our SMS texting opt-in or opt-out process.

Please verify that you are human*

When you are finished completing the form, please click the submit button below.

SMS (Text) Messaging Opt-In Form