Agreement to receive electronic communication

1.	Name:
First name	Middle name	Surname
2.	Date of birth:
MM	DD	YY
3.	Initial below:
I DO agree
Initial
I DO NOT agree
Initial
That the business may communicate with me electronically at the email address and/or phone number listed below. I am aware that there is some level of risk that third parties might be able to read unencrypted emails. I further agree that I am responsible for providing the business any updates to my email address and/or mobile phone number.
4.	Most preferred method of communication:
☐	Text message	☐	Email address
5.	I would Like to receive:
☐	Appointment reminders	☐	Information regarding billing
☐	Requests for customer satisfaction reviews
6.	Contact information
My email address	My phone number
I can withdraw my consent to electronic communications by calling/emailing: INSERT OFFICE NAME INSERT PHONE NUMBER INSERT OFFICE EMAIL ADDRESS
7. Signature	Date of signature
MM	DD	YY