Appointment Reminder Authorization Form

This form lets a patient or client authorize how they wish to receive appointment reminders, along with their consent signature.

Use this template

Please select the ways you would like to get reminders:

Phone Call Text Message Email

Patient Name

First Name

Last Name

Date of Birth

Email

Phone Number

I am over 18 years old.

Yes No

Parent/Legal Guardian Name

First Name

Last Name

Date

Patient Signature

Sign here

Parent/Legal Guardian Signature

Sign here

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