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:
Effective Date: 4/3/2025
Lippian Family Dentistry respects your privacy and is committed to protecting your personal information. This Privacy Policy explains how we collect, use, and share information when you opt in to receive SMS messages from us.
Information We Collect
When you opt in to receive SMS messages, we collect:
- Your phone number
- Consent to send SMS messages
How We Use Your Information
We use your information to:
- Send you the SMS messages you’ve opted in to receive
- Provide updates, promotions, or other relevant content based on your preferences
Sharing Your Information
We do not share your phone number or SMS opt-in information with third parties for marketing purposes.
Your Rights
You can opt out of receiving SMS messages at any time by replying with “STOP” to any message we send you.
Data Security
We implement reasonable measures to protect your personal information from unauthorized access or disclosure.
Contact Us
If you have questions or concerns about our privacy practices, contact us at 903-793-6976.
Dental Intelligence does not provide legal advice of any kind, and any and all information provided on this page may not be relied upon as such. In the event you elect to use or incorporate, in whole or in part, any sample language made available on this page into your own policies, procedures or communications, you do so at your sole and exclusive risk, and Dental Intelligence expressly disclaims all liability for such use. The sample language made available here is in no way intended as a substitute for obtaining your own legal advice, and should not be used without you first confirming with your legal counsel that the language ultimately used by you is suitable for your own business and meets your own legal needs.