Free Appointment Reminder Authorization Form Template
Appointment Reminder Authorization Form
Please complete this Appointment Reminder Authorization Form to provide consent for receiving reminders about upcoming appointments.
Please select the ways you would like to get reminders:
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I authorize the Healthcare Facility to send me appointment reminders via email that is stated below.
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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.
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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.
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The Healthcare Facility can contact with me about rescheduling or confirming existing appointments.
Patient's Name
Phone number
I am over 18 years old.
Date
Patient Signature
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