In-Clinic SMS Consent Form

Instructions for Clinics

Print this form for use during patient check-in or admission
Ensure clients initial or check the SMS consent box
Store completed forms per your clinic's record retention policy
This form complies with Twilio A2P messaging requirements

[Your Clinic Logo]

[Clinic Name]

[Address]
[City, State ZIP]
Phone: [Clinic Phone]

Date: _____________

Patient & Owner Information

Owner Name

_________________________________

Patient Name

_________________________________

Mobile Phone Number

_________________________________

Email Address (Optional)

_________________________________

📱 Text Message Updates

I agree to receive text updates about my pet's care (appointment reminders, surgery updates, discharge instructions, and follow-up questions) from [Clinic Name] via VetGeni.

Message frequency varies based on your pet's care. Message and data rates may apply.

Reply STOP to cancel at any time. Reply HELP for help.

SMS Terms: https://www.vetgeni.com/terms-sms
Privacy Policy: https://www.vetgeni.com/privacy

By checking this box, you certify you are the account holder or have authorization to receive texts at this number. Consent is not required to receive veterinary services.

Additional Consents

I consent to treatment for my pet as recommended by the veterinarian

I accept financial responsibility for all services provided

Client Signature

Signature

Date

MM/DD/YYYY

VetGeni SMS Program | Support: support@vetgeni.com

For clinic use only. Store with patient records.

Digital Version (For Online Registration)

Checkbox Text (copy this for online forms):

☐ I agree to receive text updates about my pet's care (appointment reminders, surgery updates, discharge instructions, and follow-up questions) from [Clinic Name] via VetGeni. Message frequency varies. Message and data rates may apply. Reply STOP to cancel, HELP for help. SMS Terms: https://www.vetgeni.com/terms-sms Privacy: https://www.vetgeni.com/privacy

⚠️ Important for Twilio Compliance

The checkbox must be unchecked by default
Users must actively click/check to consent
Pre-checked boxes are NOT compliant with TCPA regulations
Save a screenshot of your online form for Twilio verification