Broadmoor Dental Privacy Practices!
Patient privacy is taken seriously at Broadmoor Dental. Please review our office privacy practices by clicking this link: Broadmoor Dental Privacy Policies.
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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I have received a copy of this office’s Notice of Privacy Practices. |
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| Printed Name* |
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| Digital Signature (please retype printed name)* |
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| Today's Date* |
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We Want to REWARD you!
Each time you refer a new patient or family to our
office you will receive one of the following
$25.00 gift cards.
(Please indicate your preference.)
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Please remind your friends and family to mention your
name so we may thank you for your referrals!
*New referrals are not inclusive of your immediate family.
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| Who can we reward for referring YOU? |
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How would you like a
Digital Smile Makeover?
The LumiSmile digital smile makeover gives you
the chance to see what it could mean if you whitened and
brightened your smile, closed some gaps, changed tooth
shape, and/or fixed broken or discolored teeth. It’s free and
all it takes is a quick photograph to make it happen!
The photograph is e-mailed to Denmat for smile
design. The information they need is your photograph,
name, and phone number. Since this information is being
released, under HIPPA privacy laws, we need your approval
to release the data. So here is the consent:
I understand I have the right to receive a copy of
this authorization, I have the right to refuse to sign this authorization
and I have the right to withdraw this authorization
at any time. I acknowledge that the photograph to be
released and related information may include material that is
protected by federal law and I acknowledge the information
disclosed pursuant to this authorization may be subject to
redisclosure by the recipient. By providing my phone number
and authorization submission of a LumiSmile, I authorize
my dental office and/or Den-Mat Holdings, LLC, to contact
me at the phone number submitted within the LumiSmilmile
portal with respect to LumiSmile or LUMINEERS,
even if I am registered with the federal or state Do Not Call
registries.
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| LumiSmile Name |
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| LumiSmile Digital Signature |
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| LumiSmile Date |
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Your Smile Survey
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| Do you like the appearance of your smile? |
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| Do you like the appearance of your teeth? |
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| Do you like the color of your teeth? |
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| Do you have spaces between your teeth that you don’t like? |
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| Do you like the size and shape of your teeth? |
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| Are there old fillings or dental work that you don’t like looking at? |
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| What would you like to change the most about the appearance of your teeth? |
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