• 5742 Pickwick Rd, Centreville VA 20121
  • (703) 543-8112
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  • SmileOn Dentistry

Patient Communication Form

Thank you for choosing SmileOn Dentistry as your dentist. We look forward to meeting with you during your first appointment and want it to go as smoothly as possible. In order to assist us with this process, we ask that you please fill out the following new patient forms online and click “Submit Patient Form” once it is completed.

We are committed to keeping your personal information secure. All of our online forms are submitted via a secure connection and are HIPAA compliant.

  • PATIENT COMMUNICATION FORM

    A. FAMILY AND FRIENDS: It is the office policy of this Practice not to release confidential medical and health information regarding your treatment to family members or friends, except for 1) parent/legal guardian; 2) other persons authorized by the patient; 3) as we may reasonably infer from the circumstances (for example, if you bring a family member or friend into the exam room, we will assume, unless you object, that the person is entitled to receive information regarding your treatment); 4) in emergency situations, or 5) as otherwise permitted by the Health Insurance Portability and Accountability Act (HIPAA).

    If you anticipate that you will need or want your medical or health information to be provided to family members, friends, or caretakers/babysitters, please sign below so that we can release that information to that person. If you do not want any of your medical or health information provided to a family member or friend, please circle the “no” response. By signing below, you authorize the following people to receive information regarding your treatment or care. If you wish to add names later, please confirm this in writing.

    You may cancel this authorization to the extent allowed by law. If you do, you understand that the doctor or Practice may have already released information about you after you gave permission. You understand that cancelling this authorization would not prohibit any release of information by the Practice in reliance on your original authorization. If you wish to cancel or change this agreement, please issue a letter in writing to SmileOn Dentistry, Attn: Dr. Rohini Banavar, DMD.

  • B. ALTERNATIVE COMMUNICATIONS: You are also entitled to specify alternative, reasonable means of communication, if you do not want to be contacted in a certain way.
  • C. TELEPHONE COMMUNICATIONS: In order for SmileOn Dentistry to communicate with our patients regarding scheduling, appointments, and billing by telephone; we must have authorization to convey designated information.
  • D. ELECTRONIC ONLINE COMMUNICATION: By signing below, I agree that this practice may electronically communicate with me at the following e-mail address and text number regarding my family/patient account and/or information about any dental visit and/or treatment (Upcoming or Past).
  • By utilizing our practice’s automated electronic communication services, you agree that SmileOn Dentistry may send you any communication that can be sent through the Internet or automated program(s) to an e-mail or text that you designate. Online communications that we are affiliated with do not sell, share, or rent users’ personally identifiable information unless required by law, do not send e-mail or other communications without user permission, and do not send spam. All electronic communications from our practice will be encrypted, I am responsible for providing this dental practice any updates to my e-mail address and text, I am able to receive information electronically and store it securely away from any public computer and I can withdraw my consent to electronic communications by calling our office @ 703-543-8112.
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