COMMUNICATION PREFERENCES & CONSENT
CELL PHONE / TEXT MESSAGE CONSENT
Cell Phone Number:
Format: (000) 000-0000.
I consent to receive text messages about Account and Customer Care communication, such as appointment reminders from Kimberly Foon D.D.S. at the phone number I provided. I acknowledge that my consent is not a condition of purchase. Msg & data rates may apply. Msg frequency varies. Reply HELP for assistance or STOP to opt out of receiving messages. Privacy Policy: https://cdn.prod.website-files.com/6a0de9586a062e41afa3e8ed/6a71d719623ff2855eec4eef_Notice_of_Privacy_Practices-2.pdf
NO, I do not authorize text message communications.
EMAIL COMMUNICATION CONSENT
Email Address:
example@example.com
YES, I authorize this office to communicate with me by email regarding appointment reminders, treatment information, billing/insurance matters, and office notifications:
NO, I do not authorize email communications.
HIPAA ACKNOWLEDGEMENT
I acknowledge that I have been offered and/or received a copy of this dental office's Notice of Privacy Practices as required under HIPAA regulations.
Patient / Guardian Signature
Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
PATIENT CERTIFICATION
I certify that the above information is complete and accurate to the best of my knowledge. I understand that it is my responsibility to inform the dental office of any changes in my medical history, medications, or health status.
Patient / Guardian Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reviewed By (Internal Only)
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