Communication Preferences: Please select your preferred method of communication

Phone

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Text Messaging

Consent. I hereby authorize 183 Family Dentistry to use the provided information for the purpose of delivering healthcare services and communicating with me regarding my medical care . I understand that my information will be kept conf1dent1al and will only be shared with authorized healthcare professionals directly involved in my treatment.

I consent to the above statement:

Text Messaging Opt-In: Please initial and sign below io give your consent and opt in to receive text messages from our dental office. By opting in. you agree to receive appointment reminders, important updates, and exclusive offers via text message. Standard messaging rates may apply.

Initial:

I consent and opt In to receive text messages from 183 Family Dentistry: You can opt out at any time by replying 'STOP' 10 any message. Please note that messaging is not a secure form or communication. and we recommend discussing any sensIlIve or personal information during your office visits.

Signature:

Email: Unencrypted email is not a secure form of communication. There is some risk that any individually identifiable health information nnd other sensitive or confidential information that may be contained in such email may be misdirected, disclosed to or intercepted by unauthorized third parties. However, you may consent to receive email from us regarding your treatment. We will use the minimum necessary amount oi protected health information in any communication. Our first email to you will verify the email address you provide. I understand I can add or withdraw my consent at any time

Please return this form to our oifice or submit it online via our website. If you have any questions or need assistance, please contact us using the information provided above.

By signing below. I acknowledge that the inFormation provided is accurate and complete to the best or my knowledge.

Signature of Patient/Legal Guardian

Date

Thank you For choosing 183 Family Dentistry. We look forward to serving you!

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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