Patient Name - Aesthetic Plastic Surgery Center, LLC

Patient Name - Aesthetic Plastic Surgery Center, LLC

Patient Contact Consent
Patient Name: __________________________________________________
I hereby authorize the Aesthetic Plastic Surgery Center, LLC to contact me by telephone, cell phone,
text or email. I may revoke this authorization at any time.
My preferred method is (please circle):
Cell Phone
Home Phone
Cell Phone: ________________________
Cell Phone Provider (please circle): ATT
Verizon
May send appointment reminders via text:  Yes

Work Phone
Sprint
T-Mobile
No
Personal Email: ____________________________________________________________
May send surgical documents and/or appointment reminders via email:

Yes

No
Home Phone: _____________________
Work Phone: _______________________
____________________________________
Patient Signature
Revised 8.25.15
___________________
Date