Eastgate Family Dental
Grand Rapids, Michigan
2003 Burton St SE · Grand Rapids, MI 49506
Phone: (616) 245-9830 · Fax: (616) 245-5026
www.eastgatefamilydental.com
Patient Acknowledgment & Consent Form

Effective April 14, 2003, the federal law known as the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") requires that this office comply with certain rules regarding the maintenance of the privacy of your health information that we have collected and will collect in the future. To comply with HIPAA's requirements, we are giving you a copy of our Notice of Privacy Practices, which contains the information that HIPAA requires us to disclose regarding our privacy practices.

Michigan law also requires us to first obtain your written consent prior to disclosing any of your information except for our disclosure in connection with treatment, payment, and healthcare operations.

Initial here
Receipt of Notice of Privacy Practices

I acknowledge that I have today received a copy of the Notice of Privacy Practices from Eastgate Family Dental. I understand that this notice describes how my health information may be used and disclosed and how I can get access to this information.

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Consent to Disclosure of Health Information

I consent to the disclosure of my health information by Eastgate Family Dental as deemed necessary in order to provide me with proper treatment. I understand that such disclosure may include sharing information with other healthcare providers involved in my care, insurance companies for billing purposes, and other parties as described in the Notice of Privacy Practices.

I understand that I may revoke this consent in writing at any time, except to the extent that action has already been taken in reliance on this consent.

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Authorization for Treatment

I authorize the dental staff at Eastgate Family Dental to perform the necessary dental services I may need, including but not limited to examinations, x-rays, cleanings, and other dental procedures as recommended by my dentist. I understand that my dentist will discuss treatment options and associated costs with me prior to beginning any significant treatment.

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Clinical Photographs & Records

I authorize Eastgate Family Dental to take clinical photographs, x-rays, and other records necessary for the diagnosis and treatment of my dental condition. I understand that these records are the property of the practice and will be kept confidential as part of my dental record.

I understand that I may request copies of my records at any time, and that a reasonable fee may be charged for duplication.

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Appointment Reminders & Communications

I authorize Eastgate Family Dental to contact me regarding appointment reminders, treatment follow-up, and other dental health information via phone, voicemail, text message, or email using the contact information I have provided. I understand I may opt out of any of these communication methods at any time by notifying the office.

Patient Acknowledgment & Signature

By signing below, I acknowledge that I have read and understood the above consent and authorization sections, and that I have received a copy of the Eastgate Family Dental Notice of Privacy Practices.

Patient Signature
Date
Print Name of Patient, Parent, Guardian, or Personal Representative
Relationship to Patient
For Office Use Only

We attempted to obtain written acknowledgment of the receipt of our Notice of Privacy Practices, but could not because:

Individual refused to sign
Emergency situation prevented acknowledgment
Communication barrier prevented acknowledgment
Other (specify below)
Office Staff Name (Print)
Office Staff Signature
Date
Eastgate Family Dental · 2003 Burton St SE · Grand Rapids, MI 49506 · (616) 245-9830
Effective January 1, 2026