Patient Form

HIPAA / Privacy Acknowledgment

Please acknowledge that you have been informed of our privacy practices.

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 *

Acknowledgment

I acknowledge that I have been informed of Valley Dental Care's privacy practices. *

I consent to be contacted regarding appointments and care using the contact information I provided. *

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.