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Terms of Use
Please be aware that this is not a secure email network under HIPAA guidelines. Do not submit any personal or private information unless you are authorized and have voluntarily consented to do so. We are not liable for any HIPAA violations. Understand that if you email us, you are agreeing to the use of an unsecured method and understand that all replies will be sent in the same fashion, which you are hereby authorizing.
By checking this box you hereby agree to hold Periodontal and Implant Surgeons of Houston, including it’s doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties. By checking this box, you also agree to receive email communication from Periodontal and Implant Surgeons of Houston, including its doctors and affiliates.
HIPAA Consent & Authorization
By submitting this form, I understand that the information I provide may include personal and protected health information (PHI). I consent to the secure transmission and storage of this information by the practice for the purpose of responding to my inquiry, scheduling appointments, and providing healthcare-related services.
I understand that this online form is not intended for urgent or emergency medical situations. I will contact the practice directly or seek immediate medical care if I require urgent assistance.
I acknowledge that I have reviewed the Privacy Policy and Notice of Privacy Practices and agree to the terms described.