Patient Communication Consent Form for Orthodontic Practice

Patient Information

Name: _________________________ Date of Birth: _________________ Chart Number: __________________ Date: _________________________

Approved Communication Methods

Please check all methods you consent to for receiving communications about your orthodontic care:

• Cell Phone Calls: (_____) _____ - _______
• Text Messages: (_____) _____ - _______
• Home Phone: (_____) _____ - _______
• Email: ________________________________
• Patient Portal Messages

Types of Communications

I understand that I may receive:

• Appointment reminders
• Treatment updates and follow-up information
• Account and billing notifications
• Emergency care instructions
• Educational materials about orthodontic care

Privacy Acknowledgment

I understand that:

1. Standard text messaging and email are not secure forms of communication
2. There is some risk that health information shared via these methods could be read by unauthorized third parties
3. I can revoke this consent at any time by submitting a written request

Authorization

By signing below, I authorize [Practice Name] to communicate with me using the methods indicated above.

Signature: _________________________ Date: _________________ Relationship to Patient (if minor): _________________________

For Office Use Only

Received by: _________________________ Date: _________________ Entered in EHR: [ ] Yes [ ] No