Agreement to Receive Electronic Communication

1.	Name:
First Name	Middle Name	Last Name
2.	Date of Birth:
MM	DD	YY
3.	Initial Below:
I DO Agree
Initial
I DO NOT Agree
Initial
That the business may communicate with me electronically at the email address and/or phone number listed below. I am aware that there is some level of risk that third parties might be able to read unencrypted emails. I further agree that I am responsible for providing the business any updates to my email address and / or mobile phone number.
4.	Most Preferred Method of Communication:
☐	Text Message	☐	Email
5.	I would Like to Receive:
☐	Appointment Reminders	☐	Information Regarding Billing
☐	Requests for Customer Satisfaction reviews
6.	Contact Information
My Email	My Phone
I can withdraw my consent to electronic communications by calling / emailing: INSERT OFFICE NAME INSERT PHONE NUMBER INSERT OFFICE EMAIL ADDRESS
7. Signature	Date of Signature
MM	DD	YY