Patient Intake Form - Text Messaging Section
This section of your in-person patient intake form authorizes
Georgetown Clinics to send you text messages about your care.
Completing this section is optional and is not required to receive treatment or to complete registration.
Your consent
The patient checks this box and signs below during in-person registration. The box is not pre-checked.
What you are agreeing to
- Who sends the messages: Georgetown Clinics.
- Message types: appointment reminders, scheduling confirmations, and patient care notifications. No marketing or promotional messages are sent.
- Message frequency: varies based on your appointments and care.
- Cost: message & data rates may apply, depending on your mobile carrier and plan.
- Opt out anytime: reply STOP to any message to stop receiving texts.
- Get help: reply HELP, or call us at (678) 677-9046.
Your SMS opt-in data and consent are
not shared with third parties for their marketing.
See our
Privacy Policy
and
SMS Terms & Conditions for full details on
message frequency, rates, and how to opt out.
Patient signature
