AideWell - Client Intake Form (Communication Consent Section)

Sample of the consent language wellness practices using AideWell collect on their paper intake forms and at the front desk (point of sale). Staff record each choice in AideWell’s permanent consent log.

Communication Preferences & Consent

How may we contact you about your appointments and recommended return visits? (Check all that apply. Your choice is not a condition of receiving services and you may change it at any time.)

Text message (SMS): I expressly consent to receive automated appointment and return-visit reminder text messages from this practice (sent via its AideWell scheduling system) at the mobile number I provided below. Message frequency varies; message and data rates may apply. I can reply STOP at any time to stop all texts, or HELP for help. Texts will not contain health details.

Email: I consent to receive appointment and return-visit reminder emails at the address I provided below.

Mobile number

Email address

Client signature

Date

See the SMS Terms & Conditions and Privacy Policy. Consent records in AideWell are append-only: every grant and revocation is kept permanently with who recorded it and how it was obtained.