Consent for Electronic Communications - Mobile Dental Associates

Consent For Electronic Communications And Acknowledgement Of Receipt Of Notice Of Privacy Practices

Patient First Name

Patient Last Name

Consent to Electronic Communications Via Email

Unencrypted email is not a secure form of communication. There is some risk that any individually identifiable health information and 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 of protected health information in any communication. Our first email to you will verify the email address you provide. 

I consent and accept the risk in receiving information via email.

I consent only to receiving appointment and recall reminders via email. 

I do not consent to receiving any information via email.

Acknowledgement of Receipt of Notice of Privacy Practices

Designation of Relatives, Close Friends and Other Care Givers
I give permission to share appointment, billing or medical information with the person(s) named below:

Name and Relationship (please print)

Do we have your permission to:

Send a recall appointment reminder or notice to your home?

Yes

Leave appointment, billing or medical information on your voicemail

Yes

Relationship to the patient

Name if not the patient