Church Street Dental Care

COMMUNICATION RELEASE

PATIENT E‐MAIL AND TEXT MESSAGING

Due to the changing world of healthcare and technology, we now have the ability to provide our patients with certain types of information via e‐mail and/or text messaging.

We believe strongly in protecting the privacy of our patients. When you provide this information to us, it is only used as a way to communicate with you. In order to protect your privacy, no confidential or personal information will be sent from us via email or text messaging. We do not share the names, e‐mail addresses, and/or telephone numbers of patients with any other companies, or with any other patient.

By placing my signature below, I acknowledge that I have read and understand the above statement on emails and text messages. I hereby give permission to send messages to me via the selection(s) indicated below as means of communication. Should I have any questions, I can contact the practice at any time.

Authorization & Acknowledgements

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Patient Information

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