First Call Urology - SMS Text Message Consent Form
First Call Urology uses text messaging to communicate with patients regarding their care. By opting in, you authorize First Call Urology to send text messages to the mobile number provided below from our practice number (866) 950-5889. Text messages may include: appointment scheduling confirmations, appointment reminders 24 hours and 2 hours prior to your visit, new patient intake and registration links, post-visit follow-up care instructions and next steps, lab and imaging result availability notifications, prescription refill reminders, and general health information related to your care.
Patient Information
First Name
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Last Name
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Date of Birth
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Your date of birth for patient identification
Mobile Phone Number
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This is the mobile number where you will receive text messages
Email Address
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Your email address for our records
SMS Text Message Consent
Text Message Consent
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A
I CONSENT to receive text messages from First Call Urology at the mobile number provided above
B
I DO NOT CONSENT to receive text messages from First Call Urology
Acknowledgment and Understanding
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A
I understand that message and data rates may apply
B
I understand I can opt out at any time by texting STOP to (866) 950-5889
C
I understand that text messages are not secure and may not be appropriate for sensitive medical information
Patient Signature
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Date
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Date of consent
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