TEXT MESSAGE TO MOBILE CONSENT FORM

PURPOSE: This form is used to obtain your consent to communicate with you by mobile text messaging regarding your Protected Health Information. Lippian Family Dentistry offers patients the opportunity to communicate by mobile text messaging. Transmitting patient information by mobile text messaging has a number of risks that patients should consider before granting consent to use mobile text messaging for these purposes. Lippian Family Dentistry will use reasonable means to protect the security and confidentiality of mobile text messaging information sent and received. However, Lippian Family Dentistry cannot guarantee the security and confidentiality of mobile text messaging communication and will not be liable for inadvertent disclosure of confidential information.

I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of mobile text messaging between Lippian Family Dentistry and myself, and consent to the conditions outlined herein. Any questions I may have been answered by Lippian Family Dentistry.

Patient’s signature: Date: