Text messages from Resilience Med-Psych are optional. Choosing not to receive texts does not affect your care.
Print this page, complete the consent form below, and return it to our staff in person. You may also ask staff to read the disclosure to you in person or by phone and record your explicit consent. Do not send medical information on this form.
Staff must record your mobile number, consent date and method, and the disclosure you agreed to before enabling texts. Providing a phone number alone is not consent. The patient portal can manage your texting preferences; the form below is the consent disclosure for enrollment.
Name: __________________________________________________
Mobile number: ___________________________________________
Optional. You can leave this box unchecked and still receive care. I agree to receive appointment confirmations and reminders, scheduling updates, patient portal invitations, and billing reminders by text message from Resilience Med-Psych at the mobile number I provided. Message frequency varies (typically 1 to 10 messages per month). Message and data rates may apply. Reply STOP to opt out at any time or HELP for help. Consent is not a condition of care. See our SMS Terms and SMS Privacy Policy.
Read the SMS Terms and SMS Privacy Policy.
Signature (patient or authorized parent/guardian): _______________________
Date: _______________________
This page does not submit information online. Return the completed form to practice staff. Leave the checkbox blank if you do not consent.
Messages cover appointment confirmations and reminders, scheduling updates, patient portal invitations, and billing reminders. Frequency varies, typically 1 to 10 messages per month. Message and data rates may apply. We do not send marketing messages under this program.
Reply STOP to opt out or HELP for help. You may also turn texts off in the patient portal or ask staff to stop them. Contact (804) 699-3190 or admin@resiliencemedpsych.com for assistance.