Patient Consent for Written Notes (California)

Our office uses a secure helper system during your visit to make accurate written notes. The system listens in real time and creates written notes for your dental chart.

No recording is kept. Only the written notes become part of your record.
The notes are stored securely, in compliance with HIPAA and California privacy laws.
You can ask questions at any time.
Saying “no” will not affect your treatment, care, or relationship with our office.

Please check one: *

I agree to the use of this system to make written notes for my dental record.

I do not agree to the use of this system.

Patient Name (print) *

Signature *

Date *

Name Validation *