COMMUNICATION PREFERENCES & CONSENT
CELL PHONE / TEXT MESSAGE CONSENT
Cell Phone Number:
Format: (000) 000-0000.
YES, I authorize this office to contact me by text message regarding:
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 noritifcations:
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
-
Month
-
Day
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
Date
Reviewed By (Internal Only)
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