• Email and Text Messaging Consent Form

  • We now have the ability to email and/or text you, reminding you of your appointments. If you would like to receive this feature in the future, please read the consent below and sign.

    Consent to Email and/or Text Message for Appointment Reminders and Other Healthcare Communications: Patients in our clinic may be contacted via email and/or text messaging to remind you of an appointment to provide general reminders and information.

    I consent to receiving appointment reminders and other healthcare communications and information at that email and/or text from Large Chiropractic Clinic.

    I consent to receive text messages from the clinic at my cell phone and any number forwarded or transferred to that number.

    The cell phone number that I authorize to receive text messages for appointment reminders, feedback, and general health reminders/information is:     
    Carrier:      

     I consent to emails and text messaging, to receive communications as stated above. The email and text messaging that I authorize to receive are for appointment reminders and general health information.

  • Patient Rights

    Right to Terminate or Revoke Authorization
    You may revoke or terminate this authorization by submitting a written revocation to this office and
    contact the Office Manager.

    Potential for Re-disclosure
    Information that is disclosed under this authorization may be disclosed again by the person to which it is sent. The privacy of this information may not be protected under the federal privacy regulations. 

    -I understand that this request to receive emails and/or text messages will apply to all future appointment reminders/feedback/health information unless I request a change in writing.

    If you understand and agree with all the above policies, please sign your name below.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: