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About Us
Services
Insurance Plans
Location
Patient’s form
New Patient Form
Existing Patient Form
Authorization for release of health information
Consent for electronic messages
Telemedicine consent
Pelvic Exam
PHQ
Others
Review
Events
Non-Insured
Contact Us
Resources
East Florida Premium Medical Care
7421 N. University Drive, Suite 314 Tamarac Fl 33321
Phone: 954 724 724-3440 Fax: 954 724 3494
CONSENT TO RECEIVE TEXT MESSAGES AND EMAILS
By signing below, I authorize
EAST FLORIDA PREMIUM MEDICAL CARE
to contact me by
SMS
text message and /or
emails
to serve me better.
Phone
*
Email
EAST FLORIDA PREMIUM MEDICAL CARE
will send me text messages and /or emails through its member outreach program to help me stay healthy, including:
Timely reminders about needed doctor visits
How to get help scheduling my visits and transportation at no cost
Tips for keeping me safe
Information to help me manage my illnesses
I understand that message/data rates may apply to messages sent through East Florida Premium Medical Care to my cell phone and that I may receive up to 20 texts a per month. I know that I am under no obligation to authorize East Florida Premium Care to send me text messages as part of this program.
I may opt-out of receiving these communications for East Florida Premium Medical Care at any time by calling East Florida Premium Medical Care at 954-724-3440.
First Name
*
Middle Name
Last Name
*
DOB
*
Date Format: MM slash DD slash YYYY
Witness / Guardian Name:
Relationship
Signature
*
Date
*
Date Format: MM slash DD slash YYYY
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