TELEPHONE CONSUMER PROTECTION
CONSENT FORM

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In Office or Virtual/Online Appointments

By entering your phone number, you authorize NJ Spine and Wellness to call and/or send text messages (SMS) to the phone number entered above, with offers about their products or services, even if your phone number is on any national or state "Do Not Call" list. Message and data rates may apply. Your consent here is not based on a condition of purchase. You hereby acknowledge and agree to these communications that are not encrypted and authorize these communications which may contain private health information protected by the federal Health Insurance Portability and Accountability Act ("HIPAA") and consent to waiver of privacy rights under HIPAA.

TELEPHONE CONSUMER PROTECTION ACT PRIOR EXPRESS WRITTEN CONSENT FORM

Old Bridge Spine and Wellness Center, P.A. d/b/a NJ Spine and Wellness (“Company” or “Us”) seeks your consent to contact you (either directly, through service providers, and/or affiliates) with certain non-emergency, automated, autodialed, prerecorded, or other telemarketing phone calls and or text messages (SMS and MMS) under the Telephone Consumer Protection Act (TCPA). By signing this form, you authorize Us, our service providers, and our affiliates to contact you using:

  •  The phone and/or mobile number(s) listed below. 
  • An automatic telephone dialing system (ATDS) or artificial pre recorded voice.

PLEASE NOTE WE WILL NOT SELL YOUR CONTACT INFORMATION AND THIS CONSENT DOES NOT ALLOW THIRD-PARTIES TO CONTACT YOU ABOUT THEIR PRODUCTS OR SERVICES. ADDITIONALLY, PLEASE NOTE THAT THIS CONSENT ALLOWS US TO CONTACT YOU EVEN IF YOUR PHONE NUMBER IS CURRENTLY REGISTERED, OR IF IT IS LATER REGISTERED, ON ANY STATE AND/OR NATIONAL DO NOT CALL LIST.












Please check one of the following options:
Yes, I consent to receive communication from the Company via automated phone calls and/or text messages (SMS and MMS) for educational, marketing, advertising, appointment scheduling and appointment reminder purpose.No, I do not consent to receive automated phone calls or text messages from the Company.

If you checked off yes, which phone numbers would you like to receive communication to?


I understand that:

● I am not required to grant consent as a condition of buying or obtaining any property, goods, or services.
● I may revoke my consent at any time by emailing tcpa@spineandwellness.com.
● Message and data rates may apply.
● If my contact information changes, I should inform the Company by emailing tcpa@spineandwellness.com.

I agree that my electronic signature provided below is intended to have the same force and effect as a handwritten signature. I further agree that my electronic signature is attached to and logically associated with this document and that I have executed and adopted said electronic signature with the intent to sign this document pursuant to the New Jersey Uniform Electronic Transactions Act (N.J.S.A. 12A:12-1 et seq.) as amended from time to time as well as all other applicable law.