Periodontal Practice Communication Consent Form

Patient Information

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

Communication Authorization

I, _________________________, authorize [Practice Name] to communicate with me regarding my periodontal care, appointments, and related matters through the following methods:

Approved Communication Methods

(Please check all that apply and provide relevant information)

• Cell Phone: ________________

  • Voice Messages
  • Text Messages

• Home Phone: ________________

  • Voice Messages
  • Detailed Messages
  • Brief Messages Only

• Email: ____________________

  • Appointment Reminders
  • Treatment Information
  • Practice Newsletter

Authorized Individuals

I authorize the practice to discuss my dental information with:

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

Privacy Acknowledgment

I understand that:

• Communication through email and text messaging may not be secure
• The practice will use minimum necessary information in these communications
• I can revoke or modify this consent at any time in writing
• This consent remains valid until revoked

Signature: _________________________ Date: _____________

For Office Use Only

Received by: _______________________ Date: _____________ Entered in system by: _______________ Date: _____________