YOUR PRIVACY IS IMPORTANT TO US
How Would You Like Us To Communicate With You?
So that we are in compliance with HIPAA & the ADA, please check the box/boxes below giving consent to the dental practice or its service provider to contact you by mail, email, phone and/or text message regarding appointment reminders, information about treatments, payments, insurance, & other types of communication.
Please notify our office immediately if your contact information changes.
Check & Complete All That Apply (Please Print Clearly)