Electronic Communication Consent Form

Electronic Communication Consent Form
Electronic Communication

I consent that Parker County Imaging can provide their services and communicate with me via mobile phone, text message, voicemail, and email provided that these communications comply with privacy regulations.

Appointment Reminders, Rescheduling, and Cancellations

I understand that Parker County Imaging may contact me to remind me of upcoming appointments or to notify me of any changes. I also understand that Parker County Imaging may employ and use a third-party automated system to contact me for the purpose of confirming, rescheduling, or cancelling appointments.

Contact Information Change

I understand that it is my responsibility to notify Parker County Imaging if my contacr information changes.

Consent Cancellation

I understand that I may withdraw this consent at anytime by contacting Parker County Imaging.
I am signing this consent form on behalf of
Patient Name

First NameLast Name
DOB

MonthDayYear
Date
Signature

Clear
If patient is a minor, parent or guardian signature required.
Should be Empty: