Electronic Communication Consent Form

I consent to Aaron Tropmann DDS., PA. & Gary D. Oyster, DDS. contacting me electronically by the
email address and/or cell phone below for the purpose of receiving appointment reminders, notification
that I need to make an appointment, dental records, survey regarding dental visit, or reminders of
uncompleted treatment.

I understand that during the transmission of these messages, the information contained at one point or
another may pass through a public network and onto a personal electronic device and as such the
transmission may not be secure. However, the practice will not transmit any personal or confidential
information about your health, procedures or account status without your permission. (Please note that
email messages from our office are encrypted if the message contains any personal health information).

I agree to inform the practice if my email address or cell phone number changes. I understand and
acknowledge that I can cancel this consent at any time.

Patient E-mail

Cell Phone Number (for text messaging)

If you would NOT like to be contacted by email or text messages you may Opt Out of one or both by
initialing below.* If you change your mind at any time, you may call us at (919) 876-2087.

I elect to Opt Out of email

Yes No

I elect to Opt Out of text messaging

Yes No

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Date

*If you choose to Opt Out of electronic communication, what is the best way to contact you?

Home Phone

Work Phone

Mobile Phone

Home Phone Number

Work Phone Number

Mobile Phone Number

Do you give us permission to leave messages on these devices, such as appointment times, pre-treatment estimate amounts, pre-medication reminders (if applicable), etc.

Yes No

Your information will be encrypted.