Automated System Opt-Out Consent Form

For Certain Telephone Calls, Voicemail Transmissions, Recorded Messages and/or SMS/Text Messages.

By declining to provide your phone number, you expressly decline to receive calls and/or text or recorded messages placed by Watson Clinic LLP (“the Clinic”), its affiliates, business associates, and/or its service providers, from an automated system and/or using an artificial or pre-recorded message. These calls and messages are for health care and related purposes including but not limited to, for the purpose of appointment reminders and office closure announcements, telephonic sales calls, telemarketing and advertising possible treatment alternatives and other health-related benefits and services that may be of interest, and for the purpose of servicing your account, payment and billing, and collecting any amounts you may owe.

Opt-Out

I, decline to receive calls and/or messages at my phone number, placed by the Clinic, its affiliates, business associates, and/or its service providers, using an automated system for the selection or dialing of my phone number or the playing of an artificial voice or pre-recorded message for health care and related purposes, including but not limited to, telephonic sales calls, telemarketing and advertising possible treatment alternatives and other health-related benefits and services that may be of interest, appointment reminders and office closure announcements, and for the purpose of servicing my account, payment and billing, or to collect any amounts I may owe.*

* With respect to your choice made pursuant to this agreement, your election to opt-out of automated and artificial or pre-recorded voice calls and/or messages for purposes of collecting amounts owed on your account applies only to those types of collection calls made to your phone. The Clinic reserves the right to, and you expressly agree that the Clinic, its affiliates, business associates, and/or its service providers may, contact you via your number that we dial manually, and speak to via live person, and/or via e-mail using any e-mail address you provide to the Clinic, in order for us to service your account and to collect any amounts you may owe.

If you would like a printable version of this form to bring to the clinic, please click here.

Items in bold indicate required information.

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

Agree

First Name

Middle Initial

Last Name

Date of Birth (00/00/0000)

Clinic Number or last 4 digits of Social Security Number

Phone Number (no dashes)

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

Agree

Electronic Signature

Date (00/00/0000)

Legal representative printed name if signing for patient (Parent/Guardian of a Minor).