Agreement to Receive eCommunication

Agreement to Receive Electronic Communication

Download PDF Form

Patient Name

Date of Birth

Initial Below

Please make your selection

I Do AgreeI Do Not Agree

That the dental practice may communicate with me electronically at the email address and/or mobile phone number listed below. I am aware that there is some level of risk that third parties might be able to read unencrypted emails. I further agree that I am responsible for providing the dental practice any updates to my email address and/or mobile phone number.

I DO NOT WANT to receive Patient Satisfaction Online Reviews to my e-mail.

My most preferred method of electronic communication?

Text Messaging

I would like to receive:

Appointment Reminders/Recall VisitsInformation regarding insurance/billing

I can withdraw my consent to electronic communications at anytime by calling:

Fantastic Family Dental

(408) 819-3443

drlin@FantasticFamilyDental.com

Patients Signature

Date

3/14/2025

408-819-3443 Book Now

Office Hours

Monday09:00 AM - 05:00 PM
Tuesday10:00 AM - 04:00 PM
Wednesday09:00 AM - 05:00 PM
Thursday09:00 AM - 05:00 PM
FridayClosed
Saturday08:45 AM - 02:00 PM
SundayClosed

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