Communication Consent Form

First Name

Last Name

Consent For Communication Via Email/Text Message

Yes No

Patient Acknowledgement and Agreement

I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the use of email and text messaging as a form of communication between Dr. Tanya Vlacancich D.D.S staff and myself, and consent to the conditions and instructions outlined.

Today's Date

Patient Signature

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