First Name *

Last Name *

Date of birth *

Phone *

Email *

How do you want your consultation *

How would you like to receive your medication? *

Which office location *

Agrees to Transactional and Customer Care Messages *

By checking this box and clicking 'Submit,' I consent to receive transactional and customer care text messages from RCMC Medical Center (e.g., billing updates, account alerts, appointment reminders). Reply STOP to opt out. Reply HELP for help. Message and data rates may apply. Message frequency varies. View our Terms & Conditions at [new.rcmcmed.com/terms] and Privacy Policy at [new.rcmcmed.com/privacy]. Consents recorded separately with timestamps in our system. Opt-out via 'Reply STOP' in all messages. Examples: 'Appointment confirmed [date/time]. Reply STOP.' or 'Invoice due [date]. Pay: [secure link]. Reply STOP.

Agrees to Marketing (Optional)

By checking this box and clicking 'Submit,' I consent to receive promotional and marketing text messages from RCMC Medical Center (e.g., flash sales, health events). Reply STOP to opt out. Reply HELP for help. Message and data rates may apply. Message frequency varies. View our Terms & Conditions at [new.rcmcmed.com/terms] and Privacy Policy at [new.rcmcmed.com/privacy]. Consents recorded separately with timestamps in our system. Opt-out via 'Reply STOP' in all messages. After signup, you'll receive a confirmation text: 'Reply YES to confirm marketing texts from RCMC Medical Center. Reply STOP to opt out.' (Double opt-in required before sending marketing). Examples: '20% off checkups! Book: [secure link]. Reply STOP.' or 'Webinar [date]! Register: [secure link]. Reply STOP.'

I agree to terms & conditions and the Privacy policy provided by the company. By providing my phone number, I agree to receive text messages from the business.