TEXT/SMS COMMUNICATIONS CONSENT FORM Text Messaging / Emails and Online Access Consent / Decline Form TEXT/SMS Communication Consent FormΔ Nu Image Surgical & Dental Implant Center can now communicate with patients using simple message service (SMS) text messages and emails. These can be received with an appropriate device i.e. smart phone or tablet and can include appointment reminders and general office information. These services should not be solely relied upon, the responsibility of attending appointments or cancelling them still rests with you. You can cancel these services at any time. The messages are generated using a secure system however, they are transmitted over public networks to a personal device and as such are not secure. The practice will not transmit any information that would enable an individual client to be identified without prior consent. Please tick the appropriate box belowI *CONSENT / DECLINE (delete as appropriate) to the practice contacting me by text/email for the purposes of office information and appointment reminders. Radio Field Text/Email Text Only Email OnlyPatient NamePhoneEmailDateSignature Sign Here Submit Form