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Appointment Reminder Authorization Form -Form Fill
Q1
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.
Q2
First Name
Patient Name
Q3
Last Name
Patient Name
Q4
Date of Birth
Q5
Email
Q6
Phone Number
Phone Number
Q7
I am over 18 years old.
Yes
No
Q8
Date
Q9
Patient Signature
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