SMS/Text Message Consent Form

Print this form for patients and staff to sign when opting in to text notifications. Signed copies are retained as records of consent.

AraSync

AraSync Health Systems

136 Division Street
Waite Park, MN 56387
(669) 278-5128 · [email protected]

Text Messaging Consent

SMS/Text Message Opt-In Authorization

Complete this form to receive text notifications from AraSync Health Systems. Providing consent is optional and is not a condition of receiving any service or care.

1 Participant / Staff Information

Full Name

Date of Birth

Mobile Phone Number

Mobile Carrier (optional)

Relationship / Role (client, guardian, staff)

Care Agency / Employer

2 Consent to Receive Text Messages

By signing below, I authorize AraSync Health Systems to send text (SMS) messages to the mobile number I provided above. I understand that:

Message types: appointment and visit reminders, scheduling and shift alerts, care-coordination and documentation reminders, verification codes, and customer-care responses.
Frequency: message frequency varies based on account activity (up to approximately 10 messages per month).
Cost: message and data rates may apply — my mobile carrier’s standard charges apply to all messages.
Opt out any time: reply STOP to unsubscribe, or HELP for assistance.
Not a condition of service: consenting to texts is not required to receive care or any service.
Privacy: my mobile number and consent are never sold, rented, or shared with third parties for marketing. See the Privacy Policy and Terms linked below.

I agree to receive text messages from AraSync Health Systems at the mobile number provided, on the terms described above.

3 Signature

Participant / Staff Signature (or Legal Guardian)

Date

Printed Name

Guardian Relationship (if applicable)

✓ For Office Use Only

Form Completed On

Entered By (Staff)

Number Verified (Y/N)

Privacy Policy: arasynchealth.org/privacy-policy · Terms: arasynchealth.org/terms-of-service ARA-SMS-001 · Retain signed copy on file