Patient SMS consent intake

This workflow is designed for front desk staff to complete with the patient during intake, checkout, or referral enrollment. Patients do not need to create their own account to provide consent.

Use this screen when The Dental Studio of Midland is collecting a patient's mobile number and consent before sending referral reward, reminder, or related SMS communications.

Patient information

Collected by practice staff during intake or registration.

Patient full name

Mobile phone number

Preferred contact method

Patient status

Staff member capturing consent

SMS consent disclosure

I agree to receive SMS text messages from The Dental Studio of Midland regarding referral rewards, digital gift cards, reminders, and limited patient support or program notices. Message frequency varies. Message and data rates may apply. Reply STOP to opt out. Reply HELP for help. Consent is not a condition of purchase.I confirm that I am the subscriber or authorized user of the mobile number provided above.

Patients should be able to review the Privacy Policy and SMS Terms before submission.

Acknowledgment and staff verification

Keep a clear record of how consent was captured.

Consent capture method

Patient completed form on office tablet or phoneStaff reviewed disclosure aloud and patient agreed in office

Patient signature or acknowledgment

Signature captured here

Date

Staff initials

Staff confirmation

• I confirmed the patient's mobile number before saving the record.
• I reviewed opt-out instructions with the patient.
• I confirmed that consent is not required to receive treatment.