Patient Communication Form

How would you like us to communicate with you?

Our dental office sends appointment reminders, information about treatment, financials, insurance and other communications. Please tell us how you would like us to communicate with you:

PLEASE CALL THE OFFICE RIGHT AWAY IF YOU GET A NEW TELEPHONE #

Check or complete all that apply (please print clearly):

I consent to the following: The dental practice or its service provider may contact me to provide healthcare information such as appointment reminders, information about treatment, payment, my account or insurance, using artificial or prerecorded voice or telephone equipment that may be capable of automatic dialing. The dental practice may:

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