HEALTH-SPAN CLINICS

TEXT MESSAGE (SMS) COMMUNICATIONS CONSENT FORM – APPOINTMENT REMINDERS & UPDATES

Patient Name: _______________________________   Date: __________________

Mobile Phone Number: _________________________________________________

☐ YES, I consent to receive informational text messages from Health-Span Clinics, including:

                  • Appointment reminders and confirmations

                  • Treatment updates

                  • Account notifications

Disclosures:

• These messages are informational only (no marketing/promotions).

• Message frequency varies.

• Message and data rates may apply.

• I can opt out anytime by replying STOP or contacting the clinic.

Patient Signature: ____________________________________________________

Date: __________________

See https://www.health-span-clinics.com/messaging-terms-and-conditions and https://www.health-span-clinics.com/privacy-policy for details.