Joseph Fair Chiropractic
Performance Chiropractic & Active Recovery • Modesto, CA
SMS / Text Message Opt-In Authorization
PATIENT COPY — KEEP FOR RECORDS
Last updated: April 10, 2026
Why we collect this
Joseph Fair Chiropractic uses SMS text messages to send appointment reminders, confirmations, and scheduling updates. Providing your phone number alone does not grant permission to text you — your explicit written consent below is required. Both consent categories below are optional and will not affect your ability to receive care at this office.
Patient Information
First Name
Last Name
Date of Birth
Mobile Phone Number (for SMS)
Email Address
SMS Text Message Consent — Please Read and Initial Each Box You Agree To
Appointment Reminders & Confirmations (Optional — not required for care)
I consent to receive transactional SMS messages from Joseph Fair Chiropractic at the mobile number provided above, including appointment reminders, booking confirmations, and scheduling notifications.
Marketing & Promotional Messages (Optional — not required for care)
I consent to receive optional marketing and promotional SMS messages from Joseph Fair Chiropractic at the mobile number provided above, including health tips, special offers, clinic updates, and wellness information.
Patient Signature — or Parent/Guardian if patient is under 18
Date Signed
Printed Name of Signer — if different from patient (e.g., parent or legal guardian)
Note: If the patient is under 18 years of age, a parent or legal guardian must sign this form and must be present at the appointment to sign consent paperwork.
Privacy Notice
Your mobile phone number and SMS consent information are used solely for communications from Joseph Fair Chiropractic. Mobile information will not be shared with third parties or affiliates for marketing or promotional purposes. Text messaging originator opt-in data and consent will not be shared with any third parties, excluding aggregators and providers of the text message services necessary to deliver the SMS service. You may revoke consent at any time by replying STOP to any text message or by notifying our front desk in person or by phone.
For full details, see our Privacy Policy at josephfairchiropractic.com/privacy-policy and Terms of Service at josephfairchiropractic.com/terms-of-service. For support, call (209) 521-1122 or email [email protected].
Office Use Only — Do Not Write Below This Line
Entered in GHL
Entered By (Staff)
Date Entered
Patient ID / Chart #
How Patients Opt In
Patients provide SMS consent through one of the following methods:
- Online booking form — When scheduling an appointment at josephfairchiropractic.com/book, patients are presented with two separate, clearly labeled, optional checkboxes: one for transactional messages and one for marketing messages. Neither checkbox is pre-checked. Submitting the form without checking either box does not enroll the patient in SMS communications.
- Paper form at the office — This page represents the paper version of the same consent form. Staff enter confirmed opt-in status into GoHighLevel (GHL) after the patient signs. The form is retained in the patient file.
In both cases, consent is explicit, separate for transactional and marketing categories, and never a condition of receiving care.
Sample Messages
Appointment Reminder (Transactional)
Booking Confirmation (Transactional)
Marketing Message (Marketing — separate consent required)
In-Office Paper Form
Print this form for patients to complete by hand at the office. Staff should enter the signed consent into GoHighLevel and retain the signed copy in the patient file.