Please select the ways you would like to get reminders:

• I authorize the Healthcare Facility to send me appointment reminders via email that is stated below.

• I authorize the Healthcare Facility to send me appointment reminders via text message to phone number that is stated below. I understand that text message service is free of charge.

• I authorize the Healthcare Facility to send me appointment reminders via voice message. If I cannot answer the phone, permission to leave message to the person who answer or to answering machine is given to the Healthcare Facility.

• The Healthcare Facility can contact with me about rescheduling or confirming existing appointments.

Patient's Name

Email

Phone number

I am over 18 years old.

Date