SMS Consent Form

For clinic and facility use. Enter your facility's details below, then click Print / Save as PDF to generate a completed form ready for patient signatures.

Your Facility Information

Clinic / Facility Name

Street Address

City, State ZIP

Date

Sample Oncology Clinic

123 Medical Plaza, Suite 100

Seattle, WA 98101

April 22, 2026

Patient SMS Consent Form

Patient Name:

Date of Birth:

Mobile Phone Number:

Patient Signature

Date

Printed Name

Staff Witness

Date

Retain signed copy in patient’s medical record · Chorus Health · chorushealth.com · hello@chorushealth.com