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Specialty Benchmarks LLC
Patient Satisfaction Survey — Text Message Consent
Your anesthesia care team works with Specialty Benchmarks LLC to measure
patient satisfaction. If you choose to take part, we will text you a link to a
1-minute survey after your visit. Taking part is entirely optional.
Patient information
Facility:
Patient name:
Date of service:
Mobile phone number:
Consent to receive text messages
YES — I agree to receive survey text
messages.
By signing this form and providing my mobile phone number, I agree to
receive SMS patient satisfaction survey messages (customer care and survey/polling
messages) from Specialty Benchmarks LLC on behalf of the facility named above. I will
receive up to 2 messages per visit. Message frequency may vary. Message and data rates
may apply. Reply STOP to opt out at any time, or reply HELP for help. Consent is not a
condition of treatment, purchase, or any service. My mobile information and my consent
to this text message program will not be sold or shared with any third party for
promotional or marketing purposes. Specialty Benchmarks LLC privacy policy:
www.specialtybenchmarks.com/Home/Privacy
No thank you — I do not wish to receive
survey text messages.
Signature
Patient (or authorized representative) signature:
Printed name: Date:
Relationship to patient (if not the patient):
Questions about this program: Specialty Benchmarks LLC, 17 Campground Lane,
Oxford, ME 04270 · 1-207-688-8486 ·
customerservice@specialtybenchmarks.com ·
Program terms: www.specialtybenchmarks.com/sms-consent.html
Retain the signed original in the patient record. Form revised September 1, 2026.