Text Message Appointment Reminder Consent

Optional — You do not need to sign this form to receive care.

Patient Name

Date of Birth

Mobile Number to Receive Text Messages

By checking the box and signing below, I understand that:

Message frequency varies (typically 2–6 messages per month).
Message and data rates may apply.
I can reply STOP at any time to opt out, or HELP for help.
Consent to SMS is not a condition of receiving medical care.
Text messages may contain limited health information (such as appointment date, time, or provider name). Standard SMS is not encrypted.
The Privacy Policy and SMS Terms of Service are available at www.compassionpediatrics.com/sms-privacy and www.compassionpediatrics.com/sms-terms.

Patient / Guardian Signature

Printed Name

Relationship to Patient

Date

For office use only: Date entered into system: _____________ Staff Initials: _______