Appointment Reminder Consent Please complete this form and sign below to give your permission for Andrew J. Dietz, DDS, PA to provide an automatic appointment reminder through Solutionreach by either email, phone OR text message (All reminders are HIPAA Compliant).Select option below and provide the phone or email address you would like us to use.* Andrew J Dietz, DDS, PA may send email message reminders to confirm my upcoming appointments to: Andrew J Dietz, DDS, PA may send voicemail message reminders to confirm my upcoming appointments to: Andrew J Dietz, DDS, PA may send cell phone text message reminders to confirm my upcoming appointments to: Email PhoneName* First Last Patient/Parent/Guardian Signature*Date* MM slash DD slash YYYY *I understand by declining the notification service, I assume the full responsibility to contact the office 2 business days prior to the scheduled appointment time to confirm my visit.PhoneThis field is for validation purposes and should be left unchanged.
