AB Holistic Health
SMS/Text Messaging Consent Form

Paper Proof of Consent (For Client File)

Organization: AB Holistic Health
Website: https://abholistic.com
Contact: support@abholistic.com

Instructions: Please read carefully and complete all fields. This form documents your consent to receive SMS/text messages from AB Holistic Health. Retain a copy in the client file.

Client Information

Client Full Name: ________________________________________________

Mobile Phone Number (SMS-enabled): ________________________________

Email (optional): _________________________________________________

Preferred Language: _______________________________________________

Date of Birth (optional): _________________________________________

Consent Disclosures

Purpose: I consent to receive SMS/text messages from AB Holistic Health related to appointment reminders, scheduling updates, wellness education/resources, and important notices. Messages are non-clinical and for informational/support purposes only.

Frequency: Up to 8 messages/month, depending on activity. Message frequency may vary.

Opt-out: I understand I can reply STOP at any time to cancel. I can also request removal by contacting AB Holistic Health.

Help: For assistance, reply HELP or contact admin@abholistic.com.

Rates: Message and data rates may apply from my mobile carrier.

Privacy: Messages may traverse third-party networks. AB Holistic Health will not include sensitive health information in SMS.

Consent Not a Condition: My consent is not required as a condition of receiving services or care.

Record of Consent: AB Holistic Health may retain this form as proof of consent and may verify the mobile number provided.

Administration: Some messages may be sent using automated systems.

Updates: I agree to notify AB Holistic Health if my mobile number changes.

Consent Options

[  ] I CONSENT to receive SMS/text messages at the mobile number listed above.

[  ] I DO NOT consent to receive SMS/text messages.

[  ] I prefer appointment reminders only.

[  ] I prefer wellness education/resources only.

Standard Messaging Footer Example: “Reply STOP to unsubscribe. Reply HELP for help.”

Signatures

Client/Authorized Representative Name: ______________________________

Signature: _________________________________________________________    Date: ____ / ____ / ______

Relationship to Client (if not the client): ________________________

Staff Member Receiving Consent (print): _____________________________

Staff Signature: _________________________________________________    Date: ____ / ____ / ______

By signing above, I acknowledge that I have read and understand this consent and that I am the authorized user of the mobile number provided.