CONSENT TO RECEIVE MAIL AND/OR TELEPHONE MESSAGES

Patient Name

Do we have your consent to:

Send recall appointment reminders in the mail?

Yes

Leave appointment, billing, or dental information on your answering machine, voicemail, or email?

Yes

Share your appointment, billing, or dental information with another individual?

Yes

If yes, please list their name(s) here:

Signature

Signature of patient (or parent/guardian if minor)

Date

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.

Submit

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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