Consent to Receive Text Messages Adult Client or Parent/Guardian

By consenting to receive SMS messages, you are agreeing to be contacted by NOVA Allergy Group on behalf of your healthcare providers via text (SMS) messages to your mobile
phone and other wireless devices, and the use of an automatic telephone dialing
system, artificial voice, and prerecorded messages, for the purpose of providing
appointment services.

You may opt-out of receiving text (SMS) messages at any time by replying with the word
STOP from the mobile device receiving the messages. NOVA Allergy Group will not share,
sell or use your contact information for other purposes.

___  YES, email notifications only

___  YES, email and text (SMS) message notifications

___  YES, voice notifications only

___  YES, email, text (SMS) message, and voice message notifications

Print name of Adult Client or Parent’s/Guardian of Child Client. Date of Birth

Print Client or Parent/Guardian Name to rep
Date of Birth