Communication Agreement

Ridgefield Dental Arts

42 Danbury Road Ridgefield CT 06877
AGREEMENT TO RECEIVE COMMUNICATION

The dental office may communicate with me electronically at the e-mail address and/or phone number listed below.
Patient Name:

First NameLast Name
Email Address:
example@example.com
Phone Number:
Please enter a valid phone number.
My most preferred method of communication:
I agree that I am responsible for providing the dental practice any updates to my e-mail and/or phone numbers.

I can also withdraw my consent to electronic communications at any time in writing to: Ridgefield Dental Arts, {ridgefielddentalarts@gmail.com}
Patient/Guardian:

Clear
Date:

MonthDayYear
Date
Should be Empty:

Ridgefield Dental Arts