We use a confidential service called RevenueWell to make contact with our patients about appointments and office information. When confirming appointments we can send you an email, text or give you a courtesy phone call.
Please choose the way(s) you would like to be contacted by our office about your appointments.
Was there a reason you left your last dental practice?
Please indicate below any person or persons you give us permission to discuss your information with. (Example: Spouse, Son, Daughter, etc.) Please list any information you wish to exclude from this privacy permission. (Example: Account, Appointments, Medical Information, etc.)
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To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
