Patient E-mail and Text Messaging Consent Form


Patient Name:_____________________________________Date of Birth:__________________

Due to the changing world of health care and technology, we now have the ability to provide our patients with certain types of information via e-mail and/or text messaging. If you wish to have the opportunity to receive information of this type, please complete the form below.

  • Yes, please sign me up to receive e-mail and text messaging confirmations. 

  • I do not wish to be contacted via email. (Text messaging only)

  • I do not wish to be contacted via text messaging. (E-mail only)

  • I do not wish to be contacted by either text messaging or email.

I am aware that there is some level of risk that third parties might be able to read unencrypted emails and/or text messages.

I am responsible for providing the dental practice any updates to my email address or cell phone. 

I can withdraw my consent to electronic communications by calling: 252-504-2138


Patient E-mail Address:__________________________________________________________


Patient Cell Phone: _____________________________________________________________


Patient Signature:_________________________________________ Date:_________________

(252) 504-2138

200 Lockhart Dr, Beaufort, NC 28516, USA