Please print this page, complete it, and bring it to the clinic. You may also complete it at reception when you arrive. Leave it blank if you do not want text messages or email — it will not affect your care.
Patient name
Date of birth
1. Text messages (SMS)
I agree to receive text messages from Right Rehab, LLC about appointment reminders and billing notifications. Message frequency varies with your appointments. Message and data rates may apply. Reply STOP to opt out or HELP for help. Consent is not a condition of treatment.
Mobile number for text messages
Leave the box above unchecked if you do not want text messages.
2. Email
I agree to receive email from Right Rehab, LLC about appointment reminders and billing notifications.
Email address
Leave the box above unchecked if you do not want email.
3. What you should know
- These are the only messages we send. Appointment reminders and billing notifications. We do not send marketing or promotional text messages.
- Text message and email are not secure. They can be seen by anyone with access to your phone or inbox, and they travel unencrypted. Please do not reply with symptoms, diagnoses or other health details — call the clinic instead. By checking a box above you accept that risk for reminders and account messages.
- Consent is voluntary. It is not required to book, attend or receive treatment, and declining changes nothing about your care.
- You can change your mind at any time. See below.
4. How to stop messages
Reply HELP to any text message for help. Full details are in our Privacy Policy and Terms and Conditions.
5. Signature
Patient signatureDate
Responsible party signatureDate
