Patient Texting and Emailing Consent

Patient Texting and Emailing Consent

Shore Cardiology Consultants LLC
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Cell Phone Number*

Area CodePhone Number
Patient Email
example@example.com
1. I consent to Shore Cardiology contacting me via text messaging and/or by email for the purpose of recieving appointment reminders, scheduling and cancelling appointments, testing information, medication changes, and generalized health information.

2. I understand texting and emailing are generated using a secure facility and are trnsmitted over a public network onto a personal device and as such may not be secure.

3. I understand that I have the right to stop this service at any time by submitting my request to the front desk receptionist at Shore Cardiology.

4. I agree to notify Shore Cardiology of a mobile number change/email change or if either are no longer in my possession.
Patient/Guardian Signature*

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