Office Policy Form

Privacy Policy Link

Please include a website link to your online privacy policy. To be compliant with carrier policies, your privacy policy MUST include the following:

What personal information is collected
How personal information is used
Who personal information is shared with

Privacy policy must include clear language that SMS consent is not shared with third parties, for example: "SMS consent is not shared with third parties for marketing purposes."

Ensure that your privacy policy is easily accessible and prominently included on web forms, such as by adding a link near the consent language. As a best practice, also include a link to your privacy policy in the footer of every page on your website.

Terms & Conditions Link

Include a link to your online SMS Terms & Conditions or this information can be in your privacy policy. The Terms & Conditions must include information on the types of messages the user can expect to receive (example appointment reminders, order alerts, account notifications, etc.).

The Terms & Conditions must also include:

Messaging frequency may vary.
Message and data rates may apply.
To opt out at any time, text STOP.
For assistance, text HELP or visit our website at downtowndentalrc.com

Example language: SMS Terms of Service: By opting into SMS from a web form or other medium, you are agreeing to receive SMS messages from Downtown Dental. This includes SMS messages for appointment scheduling, appointment reminders, post-visit instructions, lab notifications, and billing notifications. Message frequency varies. Message and data rates may apply. Message HELP for help. Reply STOP to any message to opt out.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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