Client Email and Text Message Informed Consent

You may give permission to Body Connections Fitness & Massage Therapy (Laurie Idema-Wood) 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.
•	Risk of using email and text messages: The use of email and text message has a number of risks that you should consider. These risks include, but are not limited to, the following: 
•	Emails and texts can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients.
•	Senders can easily misaddress an email or text and send the information to an undesired recipient.
•	Backup copies of emails and texts may exist even after the sender and/or the recipient has deleted his or her copy.
•	Employers and on‐line services have a right to inspect emails and texts sent through their company systems.
•	Emails and texts can be intercepted, altered, forwarded or used without authorization or detection.
•	Emails and texts can be used as evidence in court.
•	Email and text messaging may not be secure, and therefore it is possible that a third party may breach the confidentiality of such communications.
•	Conditions for the use of email and text messages: Boy Connections Fitness & Massage Therapy can not 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 306-533-4387. 
•	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 directly to your therapist 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.  
•	Body Connections Fitness & Massage Therapy 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.  
•	Body Connections Fitness & Massage Therapy is not liable for breaches of confidentiality caused by you or any third party.
•	It is your responsibility to follow up with your therapist if warranted.

•	Withdrawal of consent:  I understand that I may revoke this consent at any time by so advising in writing by email, text or in person.  My revocation of consent will not affect my ability to obtain future 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. I give permission to be contacted via text message and or email.

Client Name:________________________________

Client Signature:______________________________	Date:_____________