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IMMEDIATE MED COMPLIES with HIPAA and wants to exchange text messages with you. Text messaging may not be entirely secure. To Consent or to Opt Out, PLEASE SIGN IN THE DESIGNATED AREA BELOW.

 

 

COMPLETE AS APPLICABLE:

 

  1. This request pertains to the records of

     

    ________________________________________________________.

 

 

  1. I am OPTING IN to SMS Message Texting for the following:

 

 Appointment Reminders

 

 Telephone Contact

 

 

 

3. I am OPTING Out to SMS Message Texting for the following:

 

 Appointment Reminders

 

 Telephone Contact

 

 

By my signature below I am giving my CONSENT to receive SMS Text Messages to the Cell Number on file

 

 

 

By Patient: _______________________________________ Date: ________________

Print name and sign)

 

 

or

 

 

By Patient’s Representative __________________________ Date: ________________

(Print name, sign, and describe authority)

10410 Abercorn Extension, Savannah, Georgia 31419

phone  (912) 927-6832              FAX   (912) 927-2450

HOURS

Monday-Thursday 9am-5:00pm

Last patient 4:30pm

Friday 9am-12pm

Closed Saturday and Sunday

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