FCC Rule on Pre-recorded Messages to Cell Phones
CONSENT FORM
Patient’s Name ___________________________________________
Telephone Consumer Protection Act requires prior express written consent from
patients/consumers before delivering a pre-recorded message or using automatic
dialing equipment devices.
These pre-recorded messages are calls or texts left via voicemail or texts to
patients/parents cell phone.
As a service to our clients, we provide a courtesy appointment reminder call and
possibly other important calls that may be placed using a pre-recorded message.
By providing your cell phone number, you are consenting to receiving such calls to
the cell phone numbers listed below.
Patient’s Cell Phone # _____________________________________________________
Father’s Cell Phone # _____________________________________________________
Mother’s Cell Phone # _____________________________________________________
Other’s Cell Phone # ______________________________________________________
Relationship ______________________________________________________
_____________________________________________________
Patient/Parent Signature
_____________________________________
Date