Patient Form

Communication Consent

Let us know how you'd like to receive appointment reminders and updates. You can opt out at any time.

Please do not include emergency medical information in this form. If you are experiencing a life-threatening emergency, call 911.

Select office *

ZIP code

Patient

First name *

Last name *

Phone

How may we contact you?

Standard message and data rates may apply to text messages. You may opt out at any time.

Phone calls about appointments and my care

Text messages (SMS) for appointment reminders

Email for appointment reminders and updates

Electronic signature

By typing my name below, I understand and agree that this electronic signature has the same effect as my handwritten signature.

Typed full legal name *

Date

I confirm this is my electronic signature and the information I provided is accurate.

By submitting this form, I understand that Valley Dental Care will use this information to contact me and prepare for my dental visit. See our Privacy Policy and Terms of Use.