Consent for Internet & Email Communications
I grant my permission to The Dental Dentist to upload and store confidential patient information including account information, appointment information and clinical information to the secured web site for the dental practice. I also understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and myself are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice website with my ID and password. I also agree to immediately notify the practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns.
I also understand State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my patient information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my patient information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the website on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.
I have read the information above regarding the secured uploading of patient information to the website for the dental practice and grant the dental practice permission to securely upload my patient information to the web site. By signing this consent, you authorize The Delta Dentist, PC to communicate with you via email regarding the topics listed below. We will never communicate via email regarding HIV/AIDS, substance abuse, genetic testing, or mental health. We will not sell or disclose your email address to any other person or entity. We will use only one email address to communicate with you. Please do not contact us using any other email address. If your email address changes, please contact us via telephone to update your information. Note: if you email us from work, you should be aware that your employer likely has access to email communication between us. You may revoke this consent at any time in writing. The revocation will apply only after it is received. Unless revoked, this consent will remain valid for as long as you are a patient of The Delta Dentist.
Email is not a substitute for seeing your dentist.
Email communication should never be used in an emergency or for urgent requests for information.
I consent to The Delta Dentist sending me emails regarding:
Appointment reminders
Billing information
Test results
Basic treatment advice
Special & Promotional messages