LIVE RIGHT MASSAGE THERAPY CLINIC

Client Email and Text Message Informed Consent

You may give permission to Live Right Massage Therapy Clinic ( Roxanne Senft ) to communicate with you by email and text message (also known as SMS).  This form provides information about the risks of these forms of communication, guidelines for email/text communication, and how we use email/text communication.  It also will be used to document your consent for communication with you by email and text message.

•	How we will use email and text messaging:  We use these methods to communicate only about non-sensitive and non-urgent issues.  All communications to or from you may be made a part of client file.  You have the same right of access to such communications as you do to the remainder of your client file. We will not disclose your emails or text messages to researchers or others.

•	Conditions for the use of email and text messages:  Live Right Massage Therapy Clinic cannot guarantee but will use reasonable means to maintain security and confidentiality of email/text information sent and received.  You must acknowledge and consent to the following conditions:

•	IN A MEDICAL EMERGENCY, DO NOT USE EMAIL, CALL 911.  Do not email for urgent problems.  If you have an urgent problem during regular business hours, please call 306-585-3080.  Urgent messages or needs  
•	Emails should not be time-sensitive.  While we try to respond to email messages daily, we cannot guarantee that any particular email will be read and responded to within any particular period of time.   If you have not heard back from us within three days, call our office to follow up if we have received your email.
•	You should speak Roxanne Senft to discuss complex and/or sensitive situations rather than send email or text messages regarding such situations.
•	Email and text messages may be filed electronically into your file.  
•	Live Right Massage Therapy Clinic will not forward your identifiable email/texts to outside parties without your written consent, except as authorized by law.
•	You should use your best judgment when considering the use of email or text messages for communication of sensitive medical information.  
•	Live Right Massage Therapy Clinic is not liable for breaches of confidentiality caused by you or any third party.
•	It is your responsibility to follow up with Roxanne Senft if warranted.

•	Withdrawal of consent:  I understand that I may revoke this consent at any time by so advising Live Right Massage Therapy Clinic in writing by email, text or in person.  My revocation of consent will not affect my ability to obtain future massage treatments.

•	Client Acknowledgement and Agreement:  I acknowledge that I have read and fully understand this consent form.  I understand the risks associated with the use of email and text messaging as a form of communication between Live Right Massage Therapy and me, and consent to the conditions and instructions outlined, as well as any other instructions that Live Right Massage Therapy Clinic may impose to communicate with me by email or text message.

Client Name:________________________________

Client Signature:______________________________	Date:_____________