Patient Text Message Sign-Up

Blank front-desk opt-in form · Independence OS Clinic Messaging Program

[Clinic Name]

OPTIONAL — text message sign-up. You do not have to complete this form; leaving it blank will not affect your care or any service you receive.

I agree to receive text messages from [Clinic Name] at the mobile number below: appointment reminders, appointment request confirmations, prescription refill request status updates, and replies from clinic staff or the clinic's assistant when I text. Up to 4 standard outbound messages per month, plus replies when I message the clinic. Message & data rates may apply. I can reply STOP to unsubscribe or HELP for help. This is optional and not required for my care or any clinic service.

Mobile number: ______________________ Initials: ______ Date: __________

This form is used only for text message sign-up. It is filed separately from registration and intake paperwork and collects nothing else.