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D*action Study

New Participant Registration

Participant Information

Authorization for SMS Notifications

“Yes” indicates my authorization for GrassrootsHealth to send text messages to the phone number listed below regarding important study reminders. I am responsible for any text or data fees that may apply based on my carrier and plan. I can opt out of receiving text messages at any time by texting STOP in reply. This authorization is equivalent to my signature.

Yes No     Today's Date: March 23, 2017

My mobile number is the same number as my contact phone

Mobile Phone Number:



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