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How may we communicate with you?

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

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

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.

Signature Pad

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