Patient Consent for Text Messaging
Texas Dental Practices, PLLC dba: Richardson General and Cosmetic Dentistry
Effective: 2025

We offer the convenience of communicating with you by text (SMS) messaging for purposes related to your care and account. This form explains how we use texting and asks for your consent to do so.

What You May Receive via Text:

• Appointment confirmations, reminders, or rescheduling
• Treatment plan or follow-up instructions
• Notifications about balances or insurance updates
• Occasional office updates, service notices, or patient satisfaction surveys

Important Information:

• Message Frequency: Varies based on your care; generally no more than 5
  messages/month
• Carrier Charges: Message and data rates may apply, depending on your mobile plan
• Privacy Risks: Texts are not encrypted. There is a small risk that messages could be
  intercepted or read by others (e.g., if your phone is unlocked)
• Opt-Out: You may opt out anytime by texting “STOP” to our number or calling the
  office
• No Guarantee of Immediate Response: Text messages may not be monitored 24/7.
  Do not use texting for urgent or emergency matters

Consent and Authorization

By signing below:

• I authorize Richardson General and Cosmetic Dentistry to send me text messages
  related to my dental care, appointments, billing, or office updates.
• I understand that I can withdraw this consent at any time by texting “STOP” or
  notifying the office.
• I understand the risks of communicating via unencrypted text and agree to receive
  these messages anyway.

Patient Name: __________________________________________
Mobile Number:   ________________________________________
Signature:  _____________________________________________
Date: _________________________________________________