Details of How My Organization (Midlife Medicine) Obtains SMS Opt-In
My SMS platform provider, Spruce Health, specializes in powering medical communications across many channels,
including SMS text messaging, which is used by many healthcare practices to communicate with patients and others
outside of the practice.
Please note that I, from time to time, make use of agreements that are not available on any public website, such
as agreements on paper forms or agreements that are accessible only via private online forms. So while I am
faithfully and consistently gathering SMS opt-ins via specific contractual language, as described below, this
language is not necessarily present on any publicly available website.
Paper SMS Consent Form
I use the following paper form in my standard agreement paperwork in order to collect opt-in consent for SMS
texting. When an end user visits Midlife Medicine, they are presented with the following paper form, or a
substantially similar form, to fill out and complete to obtain SMS opt-in consent.
Midlife Medicine SMS Consent Form
Consent to Receive SMS Text Messages
I consent to receive SMS text message communications from Midlife Medicine, using Spruce Health
as
its SMS text messaging service provider, at the mobile phone number I provide. These communications
may include appointment reminders, appointment changes or cancellations, account or care-related
notifications, or administrative messages related to the services provided to me. I understand that
providing consent to receive text messages is not a condition of receiving care or services.
Text Message Details
I understand that message frequency may vary and that standard message and data rates may apply
based
on my mobile carrier and plan. SMS messages are used for scheduling, administrative activities, and
care-related communications. SMS opt-in and consent data will not be shared with any third parties.
Opt-Out and Help
I understand that I may revoke my consent at any time by texting "STOP" to (571) 546-3461.
After opting out, I will receive a confirmation message confirming that I have been unsubscribed.
For assistance, I may text "HELP" or contact Midlife Medicine at (571) 546-3461.
Text Message Origin
I understand that SMS text messages from Midlife Medicine may originate from the following
organizational phone numbers:
Additional Information
More information about Midlife Medicine's SMS communications and privacy practices is available
at:
Consent Acknowledgment
Please indicate your choice below:
- ☐ Yes, I consent to receive SMS text messages from Midlife Medicine
- ☐ No, I do not consent to receive SMS text messages from Midlife Medicine
Mobile Phone Number for Text Messages
Please provide the mobile phone number where you would like to receive SMS text message
communications
from Midlife Medicine.
Mobile Phone Number: _______________________________
By providing this mobile phone number, I confirm that I am the authorized user of this number and
that I consent to receive SMS text messages at this number as described above.
Signature: _______________________________
Printed Name:_______________________________
Date: _______________________________
|
Verbal Consent
SMS opt-in consent may also be obtained verbally during an appointment with an end user. In the case of verbal
opt-in, Midlife Medicine uses a script substantially similar to the following:
Midlife Medicine Staff:
"For your convenience, Midlife Medicine, using Spruce Health as its SMS text messaging service provider, can
send you text message updates related to your care, such as appointment reminders, scheduling updates, and other
administrative or care-related messages. Message frequency may vary, and standard message and data rates may
apply based on your mobile plan.
You can opt out at any time by replying STOP, or get help by replying HELP. Additional details are available in
our
SMS Terms of Service and
SMS Privacy Policy, which we will provide
to you.
Would you like to receive these text messages? Please say yes or no."
[End User]:
"Yes."
Midlife Medicine Staff:
"Thank you. What is the mobile phone number you would like us to use for text messages?"
[End User]:
"[Provides mobile number]"
Midlife Medicine Staff:
"Great. We will send you a text message to confirm your enrollment shortly."