The Udofia Clinic
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This page is not an online sign-up. Nothing on this page is submitted to us. It shows the paper form we use in person, so you can read it ahead of time or print it. Consent is only recorded on a signed paper form during a visit, or when you text us first.

Text Message Consent Form

The Udofia Clinic, PLLC
Houston, TX · (346) 278-6634 · Fax (346) 488-6676 · info@udofiaclinic.com · udofiaclinic.com

Patient name

Date of birth

Mobile number

Is the patient authorized to receive texts at this number? (yes / no)

Optional — check this box to receive text messages

By providing your mobile phone number and checking the consent box on our SMS consent form, you agree to receive SMS messages from The Udofia Clinic, PLLC containing patient portal sign-in links and payment confirmations for copays and product purchases. Message frequency may vary. Standard message and data rates may apply. Reply STOP to opt out. Reply HELP for help. Your mobile information will not be sold or shared with third parties for promotional or marketing purposes. See our Privacy Policy at udofiaclinic.com/privacy.html and Terms of Service at udofiaclinic.com/terms.html. Consent is not a condition of care or purchase.

We do not send marketing or appointment reminder messages. You may withdraw consent at any time by replying STOP to any message, or by calling (346) 278-6634.

Patient signature

Date

Clinic use only

Consent collected by

Date and time recorded

Method (paper / inbound text)

After consent is recorded, send the confirmation message: “The Udofia Clinic: You're now opted in to patient portal sign-in links and payment confirmations. Msg freq varies. Msg & data rates may apply. Reply HELP for help, STOP to unsubscribe.”