Guardian Chiropractic, LLC
972 Western Avenue
Manchester, Maine 04351
(207) 622-3900
CONSENT FORM FOR TEXT MESSAGING REMINDERS
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I give permission/consent to receive text messages from Guardian Chiropractic, LLC or others acting on the Guardian Chiropractic, LLC behalf. As part of this consent, you represent and warrant the following:
(1) Guardian Chiropractic, LLC or others acting on their behalf may send text messages in various formats and with various contents, including but not limited to, text messages about appointment reminders. No more than 4 messages a week will be sent.
(2) You are the owner or authorized user of the mobile phone number identified below. You will notify us immediately if you are no longer the owner or authorized user of the mobile phone number identified below.
(3) If you need assistance, please reach out to a patient services representative via email, phone, or in person. We're here to help you with any questions or concerns you may have.
(4) You are solely responsible for any message and data charges associated with such text messages. If You do not wish to receive text messages from the Guardian Chiropractic, LLC or others acting on their behalf, please indicate that on this form.
____ Yes I would like to receive Text Reminders
____ No I do not wish to receive Text Reminders
Printed Name ______________________________________________
Date of Birth __________________
Signature __________________________________________________
Mobile Phone Number ( ) ______________________