Thank you for choosing Vita Bella Medical Group, P.A. of Florida ("Practice") as your healthcare provider. We offer our patients the ability to receive certain types of information via e-mail and/or text messaging. If you wish to receive information via e-mail and/or text messaging, please read and complete the form below.

We are committed to protecting the privacy of our patients. When you provide the below information to Practice, it is only used to communicate with you about your treatment or patient account. All names, e-mail addresses, and/or telephone numbers of patients are protected in accordance with applicable privacy laws.

Name: E-mail Address: Cell Phone #:

Please Check one of the following:

Yes, the Practice may communicate with me via both e-mail and text messages regarding my treatment.
Yes, the Practice may communicate with me via e-mail messages only regarding my treatment. I do not consent to receive text messages.
Yes, the Practice may communicate with me via text messages only regarding my treatment. I do not consent to receive e-mail messages.
No, do not contact me by either e-mail or text message regarding my treatment information. By selecting this option, I understand I am responsible for checking my portal for treatment information updates.

If indicated by your selection above, you expressly consent to allow us or our healthcare practitioners to email and/or text you (via SMS and/or MMS) with or regarding Personal Data (as defined in our Privacy Policy), appointments, or similar matters related to your telehealth encounters using the contact information you have provided. Your phone carrier's normal rates may apply if you have consented to receive text messages. This consent is not a condition of purchase, and you may revoke this consent at any time by emailing us at support@vitabella.com

BY SIGNING BELOW YOU ACKNOWLEDGE YOU HAVE READ AND UNDERSTAND THE TERMS PRESENTED ABOVE, AND BY ACCEPTING THESE TERMS, YOU GIVE YOUR INFORMED CONSENT TO RECEIVE E-MAIL AND/OR TEXT MESSAGES FROM RESIHEALTH UNDER THESE TERMS (UNLESS YOU CHOOSE NOT TO RECEIVE EITHER AS INDICATED ABOVE).