Cellular Device OPT-In Consent Form

By providing your cell phone number, you expressly consent to receiving calls and/or SMS/text messages on your cellular device placed by Howard Health and Wellness (the office), its affiliates, business associates, and/or its service providers, from an automatic telephone dialing system and/or using an artificial or pre-recorded voice. This could result in charges to you according to your data plan. These calls and messages will be for health care and related purposes including but not limited to, for the purpose of appointment reminders and office closure announcements, and for the purpose of servicing your account, payment and billing, and collecting any amounts you may owe.

If at any point you change or obtain a new cell phone number, or if you no longer maintain the cell phone number you originally provided to us, you agree to notify the office immediately of such change, by completing the Cellular Device OPT-IN Conset form below. If you do not have internet access, you agree to notify Howard Health and Wellness immediately of such change, in writing, at the following address: 1048 Goodlette Road, suite 101, Naples, FL 34102, attention: Dr. Corey Howard. You agree to provide your full name, address, and date of birth in your notification.

You may be held liable for failure to do so, as outlined in the following provision.

Indemnity Provision - READ CAREFULLY:

You agree to indemnify and hold Howard Health and Wellness, its officers, agents and employees harmless from any liability, loss or damage, including but not limited to, attorney’s fees, they may suffer as a result of claims, demands, costs or judgments against them arising out of alleged violations of the Telephone Consumer Protection Act (TCPA) or similar laws, resulting from autodialed or artificial or pre-recorded voice calls placed to a reassigned cell phone number(s), originally belonging to you or which you provided to the clinic, but of which you failed to timely notify the office that such number(s) was no longer assigned to your cellular device.

Opt-In

I expressly consent to receiving calls and/or SMS/text messages on my cellular device placed by Howard Health and Wellness, its affiliates, business associates, and/or messages its service providers, from an automatic telephone dialing system and/or using an artificial or pre-recorded voice, including, but not limited to, for the purpose of appointment reminders and office closure announcements, and for the purpose of servicing my account, payment and billing, or collecting any amounts I may owe. I agree to notify the office immediately if I change or obtain a new cell phone number, or no longer maintain the cell phone number provided in this provision, and expressly acknowledge that I may be held liable for failure to do so, as outlined above.

I understand that SMS/text messages and cell phone messages carry certain risks. For example, messages may be sent in unencrypted form. They could be received by others if others have access to my device or if my messages are sent to another device. I understand the risks, and I expressly consent to receiving these messages and ask Howard Health and Wellness to communicate with me in this form.

If you would like a printable version of this form to bring to the office, please let us know and one will be provided to you.

Items in bold indicate required information.

I have read this disclosure in its entirety and agree that Howard Health and Wellness, its affiliates, business associates and/or its service providers may contact me as described above.*

AgreeI do not agree

Name*

First NameLast Name

Cell Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Email*

example@example.com

Date of Birth*

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance*

AgreeDo Note Agree

Signature*

Date*

Date