Patient SMS Consent Form

Healthcare Communications Platform

Form completed at: Check-in Scheduling call During visit
1.  Patient information
First name
Last name
Date of birth (MM / DD / YYYY)
Mobile phone number
Email address (optional)
2.  SMS consent

By checking the box below, you agree to receive SMS text messages from the clinic listed above, sent through Empathia (empathia.ai), a healthcare communications platform. These messages may include:

Yes, I agree to receive SMS messages from the clinic above via Empathia at the mobile number I provided. I understand message and data rates may apply. Message frequency varies. I can reply STOP at any time to opt out, or HELP for assistance.

3.  Important terms
Opt out Reply STOP to any message at any time. You will receive one final confirmation and no further messages will be sent.
Help Reply HELP for support, or contact us at support@empathia.ai or 626-217-2048.
Rates Message and data rates may apply depending on your mobile carrier and plan.
Carriers Carriers are not liable for any delayed or undelivered message.

Your privacy: Mobile opt-in data and consent will not be shared with any third parties or affiliates for marketing or promotional purposes. For full details see empathia.ai/privacy.html.  |  For our full Terms of Service visit empathia.ai/tos.html.

4.  Signature

By signing below, I confirm that I have read and understood this consent form and voluntarily agree to receive SMS messages as described above. This consent is not required to receive medical care.

Patient signature
Date
Printed name
Relationship to patient (if signing on behalf)
For clinic staff use only
Staff name
Date consent recorded in system
Consent entered into Empathia:   Yes    No       Patient ID / Record #: ___________________________
Empathia is an ISV healthcare communications platform. Messages are sent on behalf of the clinic listed above. This form should be retained in the patient's record.