Autumn Lake Healthcare

SMS / Communication Consent Form

Facility *

Mobile Number for Text Messaging *

Contact Type *

ResidentResponsible Party / Legal RepresentativeFamily Member (Authorized)Employee

Consent to Receive Text Messages

I agree to receive SMS/text messages from Autumn Lake Healthcare

By checking this box, you are allowing to receive informational SMS communications, such as care related updates, appointment reminders and facility announcements from Autumn Lake Healthcare. Message frequency may vary. Message and data rates may apply. Reply HELP for help or STOP to opt-out.

I understand that:

I can opt-out at any time by replying STOP
I can request help by replying HELP
Message frequency may vary. Message and data rates may apply.
Consent is not a condition of receiving care or services

By checking, I agree to the Terms & Conditions and Privacy Policy.

Signature

Full Name *

Date

Signature *

Draw your signature above

This form is securely submitted to Autumn Lake Healthcare for our records. Reply STOP at any time to opt out.