SFM Messaging Policy

Date

Patient Name

First NameMiddle Name or InitialLast Name

Email

example@example.com

Phone Number for Messaging

Please enter a valid phone number.Format: (000) 000-0000.

Patient Date of Birth

Date of Birth

Responsible Party (if not the Patient)

First NameMiddle Name or InitialLast Name

Relationship to Patient

E.g. Parent, Spouse, Partner, Guardian, Sibling

Sparks Family Medicine (SFM) utilizes different modalities to communicate with patients, including phone, SMS text messaging, email, and patient portal messaging. Patient acknowledges the following regarding the use of these messaging modalities:

• Patient portal messaging is the most secure modality of messaging.
• Patients may request for Protected Health Information (PHI) to be shared by phone, SMS text messaging, and email, but these modalities are not as secure as patient portal messaging.
• SFM may share the least amount needed for operations when utilizing phone, SMS text messaging, and email.
• SFM does not engage in SMS text marketing. Should SFM engage in SMS text marketing in the future, you will receive an SMS text message to opt-in to receive marketing texts. SMS will not sell or provide your personal information to third parties.
• Customer data is not shared with 3rd parties for promotional or marketing purposes.
• By providing your phone number and agreeing to receive texts, you consent to receive text messages from Sparks Family Medicine, Ltd from 702-722-2200, 702-665-2492, or 725-222-1121 regarding appointments and other operational issues. Consent is not required.
• Message frequency varies. Message and data rates may apply.
• You can reply STOP to unsubscribe at any time or HELP for assistance. You can also contact us at 702-722-2200 or contact@sparksfamilymedicine.com for assistance.

Sparks Family Medicine would like your consent to send informational text message communications from 702-722-2200, 702-665-2492, or 725-222-1121 to your mobile number listed above, in response to your questions or to provide information relevant to your relationship with us.

Consent is not a condition of purchase. Message frequency varies. Message and data rates may apply. Reply 'STOP' to unsubscribe at any time. Reply 'HELP' for assistance or more information. We do not share your mobile opt-in information with anyone. See our privacy policy and messaging terms and conditions at https://sparksfamilymedicine.com/privacy-policy/ for more information.

Choose One:

Acknowledgement

Name of Person Signing this Form

First NameMiddle Name or InitialLast Name

Electronic Signature Acknowledgement and Consent

Authorization to Receive Password Protected Attachment

Signature

Messaging Policy Consent Form