The Perfect Smile™ (“the clinic”) supports the use of email for the purpose of communicating with our patients regarding their clinical care. A care provider may agree to communicate with you using email but is not required to do so. You may choose to communicate with the clinic using email but you are not required to do so.

If you choose use email at the clinic, signing this consent form provides the clinic with your permission to communicate with you via email and is required before we will respond to your email or send you email for the first time. This consent can be withdrawn at any time by contacting the clinic by phone or in person.

If you choose to communicate with the clinic using email, you should be aware that email messages you send to or receive from the clinic:

• may not be secure. The clinic cannot guarantee the security of any email message transmitted outside of our email system;

• may exist as an electronic or paper record within the clinic indefinitely.

For these reasons, if you use email to communicate any information, including personal health information, to the clinic, or to receive any information, you are hereby accepting the inherent risk of this information being compromised.

THE CLINIC CANNOT GUARANTEE THAT YOUR EMAIL WILL BE RECEIVED, READ OR  RESPONDED TO WITHIN ANY PARTICULAR PERIOD OF TIME. YOU MUST NOT COMMUNICATE WITH THE CLINIC VIA EMAIL FOR MEDICAL EMERGENCIES OR  OTHER TIME-SENSITIVE MATTERS.

TERMS OF USE

I understand that it is my responsibility to monitor email received at the indicated email address(es) and to advise the clinic in writing if any email address changes or should no longer be used by the clinic for email communications with myself. I understand that only this email address will be used by the clinic for communication to me.

If I am signing on behalf of my minor child, I understand that when he/she turns 14 this consent will be void and the child will have the option of signing his/her own consent for ongoing email communication with the clinic.

I understand that the clinic cannot guarantee the security of email messages that I send to or receive from the clinic.

I agree not to use email to communicate emergency or urgent information about myself and understand that the clinic does not guarantee the receipt or review of any email messages that I may send to the clinic.

I understand and agree that individual care providers may make decisions about my treatment based on information I provide through email and that this information may form part of my health record.

I understand that I may stop using email for clinical communication purposes at any time, at which point I will notify the clinic in writing of my decision to stop using email for these purposes. I understand that this consent remains effective unless and until it is withdrawn.

I understand that individual care providers may stop using email for clinical communication purposes at any time, at which point s/he will inform me in writing or notify me about this decision at the time of my next appointment.