SMS Consent Form

Download the blank consent form for printing

Pediatric Neurology Center PA, doing business as Kids Neurology

Print this blank form and return it to our office. This page does not collect or submit information online.

Optional text messaging consent

By checking the box and signing below, I agree to receive automated, non-marketing text messages from Kids Neurology at the mobile number I provide. Messages may include appointment confirmations and reminders, scheduling and registration links, and patient portal verification codes requested by me. Message frequency varies based on appointments and requests. Message and data rates may apply.

Consent is optional and is not a condition of receiving care. I may reply STOP to opt out at any time or HELP for assistance. I can also call (863) 614-1500 for help or to arrange communication by telephone.

Text messages may be visible to others with access to my phone. Please do not send medical details by text. Text messaging is not for emergencies; call 911 in an emergency.

We do not sell or share your SMS opt-in data or personal information with third parties for marketing purposes.

Review our Privacy Policy and Terms of Service before signing. Printed copies are available from the office.

☐ Yes, I agree to receive the text messages described above.

Adult patient or parent/legal guardian name: ______________________________

Mobile phone number: _________________________________________________

Relationship to patient (if applicable): ___________________________________

Signature: __________________________________ Date: __________________

Form version: October 23, 2026. Office use: retain the signed form with the consent record.