Form

How may we communicate with you?

Our dental office may send appointment reminders, information about treatment, payment and insurance, and other communications.

First Name

Last Name

Date Of Birth

I may be contacted by US Mail at the following address:

Address

City

Zip Code

For phone and text communications:

This form is optional. You are not required to sign this form, and you do not need to sign it to recieve care in our dental office.

I may be contacted by this dental office at the following numbers:

Home Phone

Cell Phone

Work Phone

By checking one or more of the following boxes, I consent to the following: Main Street Dental, or its service provider, may contact me to provide healthcare information such as appointment reminders and information about treatment, payment, my account or insurance, using artificial or prerecorded voice or telephone equipment that may be capable of automatic dialing.

This dental Practice may:

Patient/Legal Guardian Signature

Date

Please call our office right away if you get a new phone number or address.

Thank you.