Text and Email Consent Form

Please complete this form as accurately as possible.

Client Name *

First

Last

Mobile Number *

Email *

Signature *

Clear Signature

Date *

I CONSENT to the practice contacting me by:

Text Message
Email

I will ensure that I keep the practice informed of my up-to-date mobile number and email at all times, and I will notify the practice if the number is no longer in my possession.

I DECLINE to the practice contacting me by SMS text and email.

Agree

by: practice the