New Patients/Forms

Communication Consent Form

Please Read and Complete the Form Below

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Email Consent

This form is used to obtain your consent to communicate with you by email regarding your Protected Health Information. Elias Dental offers patients the opportunity to communicate by email. Transmitting patient information by email has several risks that patients should consider before granting consent to use email for these purposes. Elias Dental will use reasonable means to protect the security and confidentiality of email information sent and received. However, Elias Dental cannot guarantee the security and confidentiality of email communication and will not be liable for inadvertent disclosure of confidential information.

Text Message / Mobile Consent

This form is used to obtain your consent to communicate with by mobile text messaging regarding your Protected Health Information. Elias Dental offers patients the opportunity to communicate by mobile text messaging. Transmitting patient information by mobile text messaging has several risks that patients should consider before granting consent to use mobile text messaging for these purposes. Elias Dental will use reasonable means to protect the security and confidentiality of mobile text messaging information sent and received. However, Elias Dental cannot guarantee the security and confidentiality of mobile text messaging communication and will not be liable for inadvertent disclosure of confidential information.

I acknowledge that I have read and fully understand this consent form. I understand the risks associated with communication via email and mobile text messaging between Elias Dental and myself and or minor child, and consent to the conditions outlined herein. Any questions and concerns have been answered and addressed by Elias Dental.

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