TCPA Optin

TELEPHONE CONSUMER PROTECTION ACT (TCPA) OPT IN CONSENT FORM

Bubolo Medical, LLC ("Bubolo Medical") may utilize an automated patient notification system to quickly and efficiently notify patients of upcoming appointments and allow patients to confirm their scheduled appointment by phone, text, and email. Bubolo Medical will NOT use your personal information (including cell phone numbers) for notifications other than confirmation of appointments, and Bubolo Medical will NOT provide your information to any outside sources for solicitation or marketing purposes.

In accordance with the Telephone Consumer Protection Act (TCPA), patients are now required to "opt in" to receive automated communications on their mobile device(s). This means patients must provide express consent to receive general messages and reminders through automated calls and SMS text messages on their mobile device(s). Consent is not required if the call or text is for emergency purposes or if made directly from a doctor, nurse, or other staff member.

Please note that signature of this consent form is not required as a condition of receiving services from Bubolo Medical, and you may decline and remain a Bubolo Medical patient.

Please note that you can revoke consent to receive these messages at any time.

Please take a moment to fill out this consent form indicating your desire to receive these important messages in the future.

PATIENT/LEGAL GUARDIAN CONSENT:

I give Bubolo Medical and its staff permission to contact me via my cellular device for automated phone calls and SMS text messages for appointment reminders and confirmations. I understand that emergency notifications are excluded from this permission and will be sent as normal.