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:
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This request pertains to the records of
________________________________________________________.
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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)