Telephone Consent Form printable pdf download

Telephone Consent Form

This form is optional. You are not required to sign this form,

and you do not need to sign it to receive care in our dental office.

How would you like us to communicate with you?

Our dental office sends appointment reminders, information about treatment, payment and insurance, and

other communications. Please tell us how you would like us to communicate with you.

Your name: __________________________________________ Date: ______________________

(print)

Check or complete all that apply

(please print clearly):

❏ Contact me by U.S. Mail at the following address:

___________________________________________________________________________

❏ Contact me by email at the following email address:

_______________________________

For Phone and Text Communications

Phone Number: ____________________________

❏ By checking this box, I consent to the following: The dental practice or its service

provider may contact me to provide health care information such as appointment

reminders and 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:

❏ Call me

❏ Text me

❏ Call me and text me

Signature: ________________________________________________ Date: ____________________

Please call the dental office right away if you get a new telephone number!

For Office Use Only:

❏

Consent revoked: Date/Initials: _________/_________

❏

Possible reassigned number. Date/Initials: _______/_______

❏

Confirmed accurate. Date/Initials: _______/_________ Date/Initials: _______/________

Date/Initials: _______/_________ Date/Initials: _______/________

Telephone Consent Form