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Menu
Home
Services
Smile Design
Checkups
Emergency
Tooth Extraction
Teeth Whitening
Tooth Bonding
Wisdom Tooth Removal
Financing
About Us
Contact
Forms
Consent for Porcelain Veneers
Informed Consent
Notice of Non Show Appointment
Protected Health Information (Phi) and Notice of Privacy Practices
Payment Arrangement Form
Patient Screening Form
Protected Health Information (Phi) and Notice of Privacy Practices
PURPOSE:
This form is used to obtain your consent to communicate with you by email/text regarding your Protected Health Information.
HOLLYWOOD PERFECT SMILE., (HPS) offers patients the opportunity to communicate by e-mail/text. Transmitting patient information by e-mail/text has a number of risks that patients should consider before granting consent to use e-mail/text for these purposes. HPS will use reasonable means to protect the security and confidentiality of e-mail/text information sent and received. However, HPS cannot guarantee the security and confidentiality of email/text communication and will not be liable for inadvertent disclosure of confidential information.
I acknowledge that HOLLYWOOD PERFECT SMILE has me given the opportunity to view the "Notice of Privacy Practices"., and that I am giving my consent for the use and disclosure of my Protected Health Information as required and/ or permitted by law.
PROPOSITO:
Esta forma es usada como consentimiento de usted para comunicarse via e-mail/texto en referenda a su información de Salud Protegida.
HOLLYWOOD PERFECT SMILE., (HPS) ofrece a sus pacientes la oportunidad de comunicación via e-mail/texto. Transmitir información vía e-mail/texto tiene numerosos riesgos que el paciente debe considerar antes de otorgarnos este consentimiento para estos propósitos. HPS usará formas razonables de proteger confidencial y seguro la información mandada a usted via email/texto. Sin embargo, HPS no podrá garantizar proteger confidencial y seguro la comunicación vía e-mail/texto y no será en ninguna forma responsable si esta información confidencial es usada inadvertidamente para otros.
Yo comprendo haber leído y completamente entendido el consentimiento de esta forma. Yo comprendo los riesgos asociados con la comunicación vía e-mail/texto entre HPS y doy consentimiento a las condiciones que me han sido dadas. Cualquier pregunta que yo haya tenido me a sido aclarada.
Patient Name:
Email:
Date:
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