Read the Text Message Terms
Canyon Pain Center
Canyon Pain Center
702 E Bell Rd, Suite 112
Phoenix, AZ 85022
(602) 603-2282
info@canyonpaincenter.com

Written consent form

Consent to Receive Text Messages and Marketing Emails

Check only the messages you want to receive, then sign and date the bottom. Leaving a box blank means you will not be signed up for that type of message. None of these boxes is a condition of treatment, of scheduling, or of any purchase, and you can change your mind at any time.

Your information

Patient name
Date of birth
Mobile number
Email address

Only give a mobile number that belongs to you or that you are authorized to use. You must be at least 18 years old to opt a mobile number or email address in. If the patient is under 18, a parent or legal guardian signs this form and gives their own contact details.

Choose your messages

Yes, text me about my appointment and my care.
By checking this box I agree to receive text messages from Canyon Pain Center at the mobile number I provided about my appointment request, scheduling, reminders, paperwork, and my care. Consent is not a condition of treatment or of any purchase. Message frequency varies. Message and data rates may apply. Reply STOP to cancel, HELP for help. No mobile information is shared with third parties or affiliates for marketing or promotional purposes. See our Text Message Terms at canyonpaincenter.com/sms-terms and our Privacy Policy at canyonpaincenter.com/privacy-policy.
Also text me occasional practice news.
Separate and optional. By checking this box I agree to receive text messages from Canyon Pain Center at the mobile number I provided about new services and providers, office updates, and health information for our patients. Consent is not a condition of treatment or of any purchase. A few messages a month at most. Message and data rates may apply. Reply STOP to cancel, HELP for help. No mobile information is shared with third parties or affiliates for marketing or promotional purposes. See our Text Message Terms at canyonpaincenter.com/sms-terms and our Privacy Policy at canyonpaincenter.com/privacy-policy.
Email me practice news and offers.
Separate and optional. By checking this box I agree to receive marketing emails from Canyon Pain Center at the email address I provided about new services and providers, office updates, patient offers, and health information for our patients. Consent is not a condition of treatment or of any purchase. A few emails a month at most. Every email has an unsubscribe link at the bottom, and I can also unsubscribe by replying or calling the office. This is separate from text messages and from emails about my own care and appointments, which I will keep receiving either way. My email address is not sold or shared with third parties for their own marketing. See our Privacy Policy at canyonpaincenter.com/privacy-policy.
Appointment and care messages, practice news texts, and marketing emails are three separate programs with three separate consents. Agreeing to one does not sign you up for the others, and stopping one does not stop the others. Replying STOP to a text ends all text messages from us, because our appointment messages and our practice news are sent from the same number, 888-273-0378 — if you want to keep your appointment reminders and stop only the news, call or email the office and we will switch off just the news.

Signature

Signature of patient, parent or legal guardian
Date
Printed name
Relationship to patient (if not the patient)

Office use only

Received by (staff initials)
Date entered
Canyon Pain Center, 702 E Bell Rd, Suite 112, Phoenix, AZ 85022 · calls (602) 603-2282 · texts (888) 273-0378 · info@canyonpaincenter.com · Arizona Facility: PMC9612
Text messaging is governed by our Text Message Terms. Information you give us is handled under our Privacy Policy and, where it concerns your care, our Notice of Privacy Practices. You can also opt in online at canyonpaincenter.com/new-patients/form.