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Samantha Kennedy, DO1660 Haslett Road, #1Haslett, MI Phone: (517) 347-8420Fax: (517) 347-8420Consent for Email or Text Usage____________________________________________________ ____________________Patient Name (Print) Date of Birth____________________________________________________ ____________________Name of Patient Parent/Guardian if under 18 DateI consent to receive health care communications/information, including, but not limited to appointments, reminders, general health reminders, feedback, health information and other necessary communications/ information at the below email and/or text address from Mid-Mitten Pediatric Psychiatry.______ (Patient initials/Parent, Guardian or Legal Representative) I consent to receive text messages from Mid-Mitten Pediatric Psychiatry at my cell phone and any number forwarded or transferred to that number or emails to receive communication as stated above. I understand that this request to receive emails and text messages will apply to communication from Mid-Mitten Pediatric Psychiatry, PLLC, including but not limited to all future appointment reminders/feedback/health information unless I provide a revocation in writing.______ (Patient initials/Parent, Guardian or Legal Representative) The cell phone number I authorize to receive text messages for appointment reminders, feedback, and general health reminders/information is: ____________________________________________________Telephone Number______ (Patient initials/Parent, Guardian or Legal Representative) The email address I authorize to receive email messages for appointment reminders and general health reminders/feedback/information is: ____________________________________________________Email AddressThe practice does not charge for this service, but standard text messaging rates may apply as provided in your wireless plan (contact your carrier for pricing plans and details).____________________________________________________ ____________________Signature of Patient or Patient’s Parent, Guardian orDateLegal Representative ................
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