Authorization for Appointment Reminders

Aaisha Felder (JCO Align Your Life) offers the option to receive

an appointment reminder  48  hours or  1  day before your scheduled appointment by email and/or by phone. If you choose the reminder bv phone, you have the option of a text message or a computer-generated voice message.

Please select ONE of the following options:

- Phone Reminder (choose one).

- Text Message.

I authorize Aaisha Felder(JCO Align Your Lifeg) to send text message appointment reminders to me on v cell phone number.

Text message charges from my cell phone provider may apply.

Example of text message: “Do not reply

— reminder — You have an appointment MON 01/11 at 4:00 PM. If you have any questions, please call us at ( ) (phone number) —Thank you"

I understand that late cancellation and no-show appointment fees will apply if I cancel my appointment with less than hours' notice.

Appointment information is “Protected Health Information“ under HIPAA.

Bv signing, I give

v permission to receive appointment reminders as selected. Mv signature indicates that I am the person legally responsible for all use of the accounts, that I am at least 1s years of age, and that I agree to all terms and conditions of use for the text messaging services if applicable. I understand that this authorization can only be revoked in writing.