SMS Consent Form

SMS Consent Form

Please complete this form to authorize North Broward Oral Surgery to communicate with you by text message. Your consent is voluntary and you may withdraw it at any time.

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Name(Required)
MM slash DD slash YYYY
Email(Required)
Purpose of text communications

By submitting this form, you authorize North Broward Oral Surgery to communicate with you via SMS / text message regarding your dental care, including but not limited to:

  • Appointment reminders, confirmations, and scheduling updates
  • Pre-operative and post-operative care instructions
  • Prescription and pharmacy notifications
  • Billing statements, payment reminders, and insurance matters
  • Clinical follow-ups and treatment plan updates
  • General practice information and office closure notices
Recurring messages Msg & data rates may apply Opt out anytime — reply STOP

Message frequency will vary based on your treatment schedule and appointments. For help, reply HELP to any message or call our office at 954-753-7070. Consent is not a condition of treatment or purchase.

HIPAA & privacy disclosure

SMS / text messaging is not a fully secure or encrypted method of communication. Messages may be transmitted over carrier networks not controlled by our office. There is a risk that text messages could be accessed by unauthorized third parties.

Text messages may contain limited protected health information (PHI), such as appointment dates, procedure references, or billing amounts. Our practice will take reasonable precautions to limit the sensitivity of information included in text messages.

Your mobile phone number and any associated personal information collected in connection with this consent will not be sold or rented to third parties for their own marketing or promotional purposes. Other uses and disclosures of your information — including disclosures to service providers who assist in delivering your messages, to other healthcare providers and insurance carriers involved in your care, and as otherwise permitted or required by HIPAA and applicable law — are governed by our Privacy Policy.

All text messaging originator opt-in data and consent will not be shared with any third parties for marketing or promotional purposes.

I consent to receive SMS/text messages from North Broward Oral Surgery.(Required)
I acknowledge and accept the HIPAA and privacy disclosure regarding text message communications.(Required)
I understand my right to opt out of SMS/text message communications at any time.(Required)
I confirm that I am authorized to provide this consent for myself or as the patient's parent/legal guardian.(Required)
Electronic Signature Acknowledgement(Required)
MM slash DD slash YYYY
e.g, Parent / Legal Guardian
This field is for validation purposes and should be left unchanged.