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Informed Consent for Text Messaging

By signing below, I authorize Trecartin Family Dentistry to contact me by automated and non- automated SMS text messaging. I understand that message/data rates may apply to messages sent by Trecartin Family Dentistry under my cell phone plan.

I know that I am under no obligation to authorize Trecartin Family Dentistry to send me text messages. I may opt-out of receiving these communications at any time by notifying the front desk staff.

Information included in the text messages may include your first name, date/time of appointments, financial information and/or treatment information. I understand that text messaging is not a secure form of communication. There is some risk that individually identifiable health information or other sensitive/confidential information contained in such text may be misdirected, disclosed to, and/or intercepted by unauthorized third parties. I will notify the office immediately if I am no longer the owner or authorized user of the mobile number identified.

By signing below, I indicate that I am the primary user for the mobile phone number listed above. I accept the risk explained above and consent to receive text messages from Trecartin Family Dentistry to the phone number that I have provided.

Additional family members that can use this number as well are as follows:


All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.