Patient Consent Form for Text Messaging

Procision Software, Inc.

Patient Communication Consent Form

By signing below, you consent to receive text messages from Procision Software, Inc. ("Procision") on the mobile number provided. These messages may include, but are not limited to, appointment reminders, patient assessments, and other non-marketing notifications relevant to your care.

Terms of Consent

1. Purpose of Messages

   • Text messages will only be used for healthcare-related purposes such as appointment reminders, assessments, and other notifications pertinent to your care.

   • Procision will not use text messages for marketing purposes.

2. Message Frequency

   • The frequency of text messages may vary depending on your interaction with our services and your care plan.

3. Charges

   • Message and data rates may apply based on your mobile carrier and plan. You are responsible for any charges incurred.

4. Opt-Out Instructions

   • You may opt out of receiving text messages at any time by replying “STOP” to any message. If you need assistance, reply “HELP” or contact us directly at support@procision.com.

5. Privacy

   • Your personal information will be kept confidential in compliance with all applicable privacy laws and regulations, including HIPAA, where applicable.

6. Accuracy of Information

   • You are responsible for providing an accurate mobile number and updating it as needed.

Acknowledgment and Consent

By signing below, I confirm that:

• I am the owner of or have the legal authority to use the mobile phone number provided.

• I understand that I may withdraw my consent at any time by replying “STOP” to any text message or contacting Procision directly.

• I acknowledge that I have read and understood the terms of this consent and voluntarily agree to receive text messages as described above.

Patient Information

• Full Name: _________________________________

• Mobile Number: ____________________________

• Date of Birth: ______________________________

Signature
I consent to receive text messages from Procision Software, Inc. in accordance with the terms outlined above.

Patient Signature: ____________________________
Date: _____________________________________