RECEIVE APPOINTMENT REMINDERS VIA EMAIL AND TEXT!!

    PLEASE PICK A SOURCE IN WHICH YOU WOULD LIKE TO RECEIVE APPOINTMENT REMINDERS

    Email Address:

    Cell Phone: (MUST REPLY WITH "Y" WHEN PROMPTED)

    We use this information to provide you with excellent treatment. We may disclose Patient Health Information (PHI) to third partiest that perform services for Kyrene Family Dentistry in the administration of your benefits in accordance with HIPPA. These partiest are required by law to sign a contract agreeing to protect the confidentiality of you PHI. You PHI may be disclosed to an affiliate that performs services for Kyrene Family Dentistry in the administration of your benefits. Our affiliates do not sell, share or rent our user's personality identifiable information unless required by law, do not send and e-mail or other communications without user permission, and do not send spam.

    Please sign below that you agree to allow us to use this information in providing your services.

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    Date:

    Please enter your email address so you can get a copy of this agreement: