USE THIS FORM FOR PEOPLE WHO DO NOT WANT TO RECEIVE SMS REMINDERS:

Patient Identifier (CIS #):

Reason:

No text plan
No cell phone
Not interested
Concerned about confidentiality
Don't plan on attending appointment
Don’t need a reminder-familiar with appt time/place
Prefers a phone call
Do not want to be inundated with texts
Other:

Please select a inpatient provider (required):

Albert Einstein Belmont Belmont, child/adolscent Brooke Glen Behavioral Hospital Brooke Glen, child/adolscent Devereux Fairmount Behavioral Health System Fairmount, child/adolscent Foundations Friends Hospital Friends, child/adolscent Hahnemann University Hospital Horsham Clinic Horsham, child/adolscent KidsPeace Kirkbride Mercy Fitzgerald North Philadelphia Health System (NPHS)/Girard Temple University Hospital/Episcopal Pennsylvania Hospital Thomas Jefferson University Hospital