Email & Text Consent/Emergency Contact
Email and Text Messaging Program Consent Form

We are happy to provide our patients with the option to participate in our online patient communication system.  Some of the features include the ability to:

Request appointments via email or text
Confirm appointments via email or text
Submit patient satisfaction surveys
Correspond with our staff via email and text with various non-urgent questions and concerns

You may choose to discontinue your participation in our online communication system at any time simply by clicking the “unsubscribe” link found at the bottom of each email, or by replying “STOP” to a text message from us.  Standard text messaging rates may apply.

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Email *
Patient First and Last Name *
Patient Date of Birth *
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First and Last Name of Person Completing Form
Relationship of person Completing Form *
Patient Address, City, and Zip Code *
Cell/Home Phone Authorization: I authorize contact by Hope419 to this phone number: *
Is it okay to leave messages on this phone number? *
Is it okay to communicate via text to this number (regarding medication refills, appointment reminders, etc)? *
Email Authorization: I authorize contact by Hope419 to the following email address: *
Is it okay to email appointment reminders and practice information? *
In case of an emergency, please provide an emergency contact person #1. Please provide name, relationship, and phone number. *
In case of an emergency, please provide an emergency contact person #2. Please provide name, relationship, and phone number. *
By typing your name below, you authorize contact to and by the means of communication detailed above. (Please type the full legal name of the person completing this form. By doing so, you agree that your typed signature has the same validity and meaning as your handwritten signature.) * *
Date Signed *
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