Request an Appointment with Black Orthodontics

Phone: 828.277.7103 E-mail: info@www.kblacksmiles.com

Appointment Request

Personal Information
Name*
First Last

Address
Street Address City State ZIP Code

Home Phone*
Alternate Phone
Email

Appointment Details
What is the nature of your appointment:
Are you currently a patient with us:

Yes

No
Additional Information:
Untitled*
I am aware a complete notice of Privacy Practices is available upon my request. The Notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, how I may exercise these rights, and the practice's legal duties with respect to my information.
Untitled*
I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all protected health information residents at, or controlled by, this practice. I understand I can obtain the practice's current Notice of Privacy Practices on request.
Untitled*
Although exposure is unlikely, I accept the risk and consent to treatment in the Era of COVID-19.
View full Supplemental Informed Consent.