Agreement to Receive Electronic Communication

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Check Below *

That the business may communicate with me electronically at the email address and/or phone number listed below. I am aware that there is some level of risk that third parties might be able to read unencrypted emails. I further agree that I am responsible for providing the business any updates to my email address and / or mobile phone number.

I agree

I Do NOT agree

Preferred Method of Communication *

Text Message

Email

I would like to receieve: *

Appointment reminders

Requests for customer satisfaction reviews

Information Regarding Billing

Contact info: Phone *

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I can withdraw my consent to electronic communications by calling / emailing:

LIFESTYLE MEDICINE OPTIONS (503) 442-0226 info@lifestylemedicineoptions.com

I have read this

Electronic Signature *

First Name

Last Name

Signing Date *

MM

DD

YYYY