Electronic Communication Consent Form

Electronic Communication Consent Form
I consent that Autism Spectrum Mandate Services can provide their services and communicate with me via mobile phone, messages, e-mail and any kind of online communications, provided that these comminications comply with privacy regulations.

Appointment Reminders, Reschedules and Cancellations

I understand that Autism Spectrum Mandate Services can reach me any time to remind me of my appointments or let me know in case of any change about my appointments. And I also understand that Autism Spectrum Mandate Services can employ and use a third-party automated system to reach out me for the purpose of "confirm", "reschedule" or "cancel".

TeleHealth Appointments

For telehealth, I understand the appointments will be held via electronic environments.

Contact Information Change

I accept that I am responsible of notifying Autism Spectrum Mandate Services when my contact informations change.

Consent Cancellations

I know that I can revoke this consent at any time by contacting Autism Spectrum Mandate Services.
YesNo
YesNo
YesNo
MyselfMy familySomeone as a legal guardian
Client Name

First NameLast Name
Client Date of Birth

MonthDayYear
Date
What is your relationship with this person?
Your Name

First NameLast Name
Date of Sign

MonthDayYear
Date
Signature

Clear
Should be Empty: