Appointment Reminder Authorization
Client Name
*
First Name
Last Name
Client Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Client ID
It is a courtesy of Health Solutions to offer appointment reminders to our clients. By signing below I am authorizing reminder communication in the following format:
Telephone
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Telephone (voice reminder only)
Please enter a valid phone number.
Format: (000) 000-0000.
Text
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Opt Out of Appointment Reminders
Click here to verify that you do not want to receive any type of reminder communication.
Signature
I understand it is my responsibility to notify Health Solutions of any change to telephone numbers, text or E-Mail forms of communication.
By signing your name electronically on this document, you are agreeing that the signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.
*
Agree
Disagree
Client Signature
Submit
Should be Empty: