TEXT MESSAGING and SMS COMMUNICATIONS CONSENT FORM

I understand that by completing this consent form I am informing Dr. Shapiro whether or not I agree to receive and/or send text messages and any other form of SMS communications with Dr. Shapiro. 

I have chosen to complete this Consent Form directly on paper, will print out this completed form and will provide this form directly to Dr. Shapiro at the time of my first session with Dr. Shapiro

I have fully read and understand Dr. Shapiro’s office Privacy Policy and Terms of Service and have made the following determination:

(Please check one of the boxes below)

☐  I DO consent to opt-in to sending and receiving text messages with Dr. Shapiro. I understand that I may opt-out at any time by texting STOP to Dr. Shapiro.  I understand that Messaging frequency may vary for Bruce Shapiro, M.D.  and that messaging and data rates apply. I further understand that, for assistance I can text HELP to Dr. Shapiro, or contact Dr. Shapiro by telephone at (203) 327-4144 or by email at BruceShapiroMD@gmail.com, orBruceShapiroMD@gmail.com,  or I may visit his website at www.Bruce ShapiroMD.com. I have been informed that I may access Dr. Shapiro’s Privacy Policy at www.bruceshapiromd.com/privacy-policy and his Terms of Service at www.bruceshapiromd.com/terms-of-service.  

☐  I DO NOT consent to, and I opt-out, of sending and receiving text and SMS messages with Dr. Shapiro. I understand that I may opt-into at any time by providing a new written and signed consent form opting into text and SMS messaging with Dr. Shapiro.  I further understand that, for assistance, I can contact Dr. Shapiro by telephone at (203) 327-4144 or by email at BruceShapiroMD@gmail.com, and that I may visit his website at www.Bruce ShapiroMD.com. I can also review Dr. Shapiro’s Privacy Policy at www.bruceshapiromd.com/privacy-policy and Dr. Shapiro’s Terms of Service at www.bruceshapiromd.com/terms-of-service

Print Name:     ___________________________________________________

Signature:         ___________________________________________________

Date:                   ___________________________________________________

Witness name:                ___________________________________________________

Witness signature:        ___________________________________________________

Date:                                    ___________________________________________________