Compliance & Privacy

Patient Consent Form Template

This is the NearCare-branded reference template for the Privacy Notice and Patient Consent for Processing of Personal Information, used across onboarding and first facility booking consent flows. The template includes disclosure of facility-based care continuity access, internal referral handoff access, and consent-gated historical data controls for clinical notes, prescriptions, referrals, diagnostic records, uploaded files, and specialty documents.

SMS / Text Messaging

Text Messaging Opt-In Templates

Reference templates for obtaining explicit consent before enrolling a patient in NearCare appointment text messages. Use the version that matches how consent is collected — verbal, web form, or paper form. Each template includes the disclosures required for messaging-program registration. The patient's mobile number is used solely to send NearCare appointment messages; it is never sold or shared with third parties for their own marketing.

1. Verbal Opt-In Script

Read aloud to the patient. Record their explicit “yes” before enrolling them.

“NearCare can send you appointment text messages — including booking confirmations, reminders, and reschedule or cancellation notices — to your mobile number.

Message frequency varies based on your appointment activity. Message and data rates may apply. Reply HELP for help and STOP to cancel at any time. Our Terms of Service and Privacy Policy are available at nearcare.app/terms and nearcare.app/privacy.

Do you agree to receive these recurring automated text messages from NearCare at this number — yes or no?”

If the patient says yes: “Thank you — you're now enrolled in NearCare appointment text messages. Reply STOP at any time to cancel.”

2. Web Opt-In Form

Reference layout for an embedded web form. The consent checkbox must never be pre-selected — the patient actively checks it.

3. Paper Opt-In Form

Printable in-store form. Keep signed physical copies as records of consent.

NearCare Appointment Text Message Sign-Up

NearCare appointment text messages — booking confirmations, appointment reminders, and reschedule or cancellation notices.

Mobile phone number

 
 

Signature

 

Date

Terms of Service: nearcare.app/terms · Privacy Policy: nearcare.app/privacy

QR code

Disclosures included in every template

  • Description of the service and message content.
  • Message frequency varies based on your appointment activity.
  • Message and data rates may apply.
  • For help, reply HELP or email luke@foresythe-health.com / call +18133998268.
  • To opt out, reply STOP at any time.
  • Links to the Terms of Service and Privacy Policy.
  • An explicit request for consent (the patient must opt in).