RG & Co

SMS Text Message & Email Communication Consent Form

RG & Co | 5815 Ellsworth Avenue | Pittsburgh, PA 15232 | (412) 681-0690

Email and Text Communication

By signing, I allow RG & Co to communicate with me about my appointments using electronic mail (e-mail) and/or text message (SMS) communication.

Important Points:

E-mail and text messages are not private or “secure”.
E-mail and text messages can be altered or “forged”.
Backup copies of e-mail or text messages may exist even after it has been deleted.
E-mail and text messages may not be seen or answered right away. Please call for urgent issues.

Text Message Reminder Request:

I request that RG & Co send text messages to a mobile device of my choosing to remind me of the date and time of my scheduled appointments. I understand my wireless carrier may charge me for such messages.
I understand RG & Co does not receive text message replies to reminder texts beyond automated responses for confirming or canceling scheduled services. I will not receive a reply from RG & Co if trying to respond to reminder notification in any other way. RG & Co provides this text reminder service as a convenience to its clients.
I understand I will need to complete a new Email and Text Message Communication Consent Form if I would like to be contacted at a different number or email address.
I understand that text message notifications will be sent:
- SAME DAY APPOINTMENT IS MADE CONFIRMING MY BOOKING(S).
- TWO DAYS PRIOR TO MY BOOKED SERVICES (WHERE APPLICABLE).
- ONE DAY & SAME DAY REMINDER NOTIFICATIONS MY OCCUR IN SOME INSTANCES BASED THE BUSINESSES NOTIFICATION SCHEDULE(S).

I understand that RG & Co requires at least 24 hours’ notice for cancelation of booked services and late cancelations may result in potential cancelation fees.

Additional Legal Information

You may withdraw or cancel this authorization at any time by replying to any previous text communication with STOP or if the communication received was in email form by using the Unsubscribe link at the bottom of the email. You may also contact RG & Co in person or by calling (412) 681-0690 to withdraw or cancel your authorization. Your withdrawal will be specific to the subscribed notification service can but may not automatically apply to both e-mails or text messages.
A personal representative (for example: a legal guardian or parent) may sign this authorization after RG & Co receives documentation of the personal representative’s authority to act for the client.

RG & Co

SMS Text Message & Email Communication Consent Form

RG & Co | 5815 Ellsworth Avenue | Pittsburgh, PA 15232 | (412) 681-0690

I (we) understand the information stated above and understand that e-mail and text messages are not a secure means of communication. I understand that the provider may decline to communicate via e-mail or text message depending on the nature of the information. I give permission for RG & Co to use electronic mail (e-mail) and text message as a means of communication regarding my services. I understand that I may withdraw this authorization at any time by notifying RG & Co in person, over-the-phone, or in writing.

Customer’s Information:

Customer Email Address(es):

Customer Cell Number(s):

Customer’s Authorization:


Customer Name (Printed)		Date

Customer’s Signature

If Customer is a MINOR or Represented by an Authorized Third Party:


Representative Name (Printed)		Date


Representative’s Signature		Relationship of Representative

Change Signature Style

John Smith

Check here to confirm that you have read the consent form and agree to receive text and email communications from RG & Co.