Dental Practice Communication Consent Form

Patient Information

Name: _________________________ Date of Birth: _____________ Patient ID: _____________________ Date: _____________________

Communication Preferences

I, the undersigned, authorize [Practice Name] to contact me using the following methods regarding my dental care, appointments, treatment, insurance, and accounts:

Approved Communication Methods (please check all that apply):

□ Cell Phone: _________________ □ Voice Messages Allowed □ Home Phone: ________________ □ Voice Messages Allowed □ Work Phone: _________________ □ Voice Messages Allowed □ Email: ______________________ □ Appointment Reminders □ Text Messages: ______________ □ Appointment Reminders

Additional Authorized Contacts

I authorize the release of my dental information to the following individuals:

1. Name: _________________ Relationship: _________ Phone: _________
2. Name: _________________ Relationship: _________ Phone: _________

Terms and Conditions

• I understand that this authorization remains valid unless revoked in writing
• I acknowledge that communication over email/text is not encrypted and may pose privacy risks
• I understand that standard message and data rates may apply for text messages
• I have the right to revoke this consent at any time by submitting a written request

Signature

Patient/Guardian Signature: _________________ Date: _________

For Office Use Only

Received by: _________________ Date: _________ Entered in system by: _________ Date: _________