This form gathers your consent to receive text messages from [Medical Practice Name] on your mobile phone. These messages may include appointment reminders, health tips, treatment updates, and other practice-related information.

Privacy & Security:
I understand that text messages are not entirely secure and there could be a risk of unauthorized access. However, Brain Health USA will take reasonable measures to ensure the privacy and security of my health information as per applicable laws.

I acknowledge that while Brain Health USA does not charge for sending text messages, my mobile carrier's standard messaging and data rates may apply.

Opting Out:
I understand that I can withdraw my consent and opt out of receiving text messages at any time by texting "STOP" in reply to any message or by contacting Brain Health USA directly at the phone number provided above.

By signing below, I confirm that I have read and understood this consent form, and I agree to receive text messages from Brain Health USA under the terms described above.


I hereby give consent to Brain Health USA and its authorized representatives to send text messages to my mobile phone number provided above. I understand that these messages may include, but are not limited to, appointment reminders, health-related tips, updates about treatments I am receiving, and occasional practice updates or announcements.

Clear Signature

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