SMS Consent Record Template
1. Contact Information
- Full Name: __________________________
- Phone Number: _______________________
- Email (optional): _____________________
2. Consent Type
☐ Verbal Consent (in person / phone call)
☐ Written Consent (form / email / text reply)
3. Consent Narrative
(Document exactly how consent was obtained. Example: “On 09/30/2025, John Doe verbally consented over the phone to receive SMS reminders at 555-123-4567. He was informed of message frequency, possible carrier rates, and opt-out instructions.”)
4. Disclosure Provided
☐ Explained message purpose (e.g., reminders, updates, announcements)
☐ Explained message frequency (e.g., occasional / weekly)
☐ Disclosed that message & data rates may apply
☐ Provided opt-out instructions (STOP)
☐ Provided help instructions (HELP)
5. Date & Time of Consent
- Date: ________________
- Time: ________________
6. Consent Obtained By
- Staff Name: __________________________
- Role/Title: ___________________________
7. Signature (if written)
- Contact Signature: ____________________
- Date: ________________
Example Completed Entry (Verbal)
- Full Name: Jane Smith
- Phone Number: 555-987-6543
- Consent Type: ☑ Verbal
- Consent Narrative: On 09/30/2025, Jane Smith verbally consented during a phone call to receive SMS appointment reminders. She was informed about message frequency, data rates, and opt-out option (STOP).
- Disclosure Provided: ☑ All boxes checked
- Date & Time: 09/30/2025, 2:15 PM
- Consent Obtained By: Barry Schoedel, Program Director