Consent for Internet Communications

I grant my permission to the dental practice 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 understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I 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 web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns.

I also understand that 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 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 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 web site 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 web site for the dental practice, and grant the dental practice permission to securely upload my patient information to the web site.
  • Social Media Consent Form

    Smiles By Hanna utilizes Facebook, Twitter, Instagram, Linkedin, YouTube, Google+ and other social media platforms for the free exchange of information, customer service as well as marketing. At times we will take pictures of our various patients during their dental visit, before and after treatment to show progress or simply to acknowledge a great experience. We will potentially post them to the various social media outlets that we use, as well as to our website. We will not post a picture of you or your family (if applicable) without your consent. In situations where there is a group shot, or you or your child are in the background, we will not mention you or your child by name in any of the captions. By checking the box below, I (the patient or guardian) acknowledge that I have read this statement and understand the contents.
  • I, the above named patient, do hereby give my consent to Smiles By Hanna to use pictures and video that include myself or my child in their various social media campaigns. By signing this sheet, I understand that they may still use pictures of myself or my child even after our treatment has discontinued or we have left this dental practice.
  • Use your finger or mouse to draw your signature in the box.
  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.