All information obtained from you by this office is protected and kept confidential. Every reasonable measure is taken to prevent unauthorized disclosure of your protected health information.

Uses and Disclosures

• Your protected health information is accessed and used for healthcare-related purposes only.

• Your protected health information is never sold, rented, transferred, exchanged, or used for non-healthcare related purposes, including marketing activities, without your written authorization.

• Your protected health information may be disclosed to third-party entities for the purpose of treatment, obtaining payment for treatment , and for healthcare operations.

  Certain Circumstances

Your protected health information may be disclosed without your written authorization in certain limited circumstances, including:

• Medical emergencies

• Situations required by law

• Individuals involved in your care

• When requested by a public health agency

• When requested by law enforcement agency

  For any purpose other than treatment, obtaining payment, healthcare operations, or the circumstances listed above, we will obtain your written authorization prior to use or disclosure. You may revoke such authorization in writing at any time

  Patient Rights

• You have the right to request and obtain a copy of your health information.

• You have the right to request alternative methods of communication.

• You have the right to request amendment or correction of your health information.

• You have the right to request restrictions on certain uses and disclosures.

• You have the right to request an accounting of disclosures made by this office.

  Changes to This Notice

  We reserve the right to change our privacy practices and the terms of this notice at any time. Updated notices will be made available to you.

  GENERAL DENTISTRY INFORMED CONSENT

• Examinations and X-Rays

  I understand that visits may require dental radiographs to diagnose and develop a treatment plan.

• Medications and Anesthesia

  I understand medications and anesthetics may be used and carry risks such as allergic reactions, swelling or dizziness.

• Changes in treatment plan

  I understand treatment plans may change based on findings during procedures.

• Temporary jaw discomfort

  I understand dental treatment may cause temporary jaw discomfort.

• Cleanings

  I understand cleanings are preventative and may require further treatment if disease is present.

• Fillings

  I understand fillings may require additional treatment and sensitivity is common.

• Extractions

  I understand risks including pain, swelling, and possible complications.

• Restorations

  I understand crowns, bridges, and veneers may require adjustment.

Last edited on 4/17/2026