Patient Information

First Name

Last Name

Parent or Guardian Information *

First Name

Last Name

Cell Phone / Best Number *

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Name of Dental Insurance Policy Holder *

First Name

Last Name

Date of Birth of Policy Holder *

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DD

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PLEASE READ *

TERMS & CONDITIONS / Effective Date: 01/01/2025 By opting in to receive SMS messages from Summerfield Pediatric Dentistry & Oral Surgery - SPD Orthodontics, you agree to the following terms: SMS MESSAGING SERVICE By providing my phone number, I consent to receive SMS / text messages for appointment reminders, marketing messages, and general two-way communication. Message frequency varies. Message data rates may apply. Reply HELP for support. Reply STOP to opt out. MESSAGE FREQUENCY You will receive messages about your appointments, forms, consents, office promotions or events. MESSAGE & DATA RATES Message and data rates may apply based on your mobile carrier’s terms. PRIVACY POLICY Your information will be handled in accordance with our Privacy Policy, which can be viewed at: https://www.summerfieldpediatricdentistry.com/s/HIPPA-tnzp.pdf OPT-OUT INSTRUCTIONS You can opt-out at any time by replying “STOP” to any SMS message. Reply "HELP" for support. You may also contact us directly at our office number (914 )472-2929. LIABILITY We are not responsible for any charges, errors, or delays in SMS delivery caused by your carrier or third- party service providers. By opting in, you confirm that you are the owner or authorized user of the phone number provided and that you are at least 18 years old.

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