By submitting this form, you are agreeing to allow us to publish your survey on our website and social media channels.

First Name and Last Initial:

Email:

Mobile Phone Number:

Procedure *Required

Was This Your First Visit To Our Practice?

Yes No

Will You Return Here For Additional Care If Needed?

Yes No

Would You Recommend Our Office To A Friend?

Yes No

Courtesy & Friendliness Shown To You By Our Staff Over The Phone:

Star Rating for Courtesy & Friendliness Shown To You By Our Staff Over The Phone:

Wait Time:

Star Rating for Wait Time:

Overall Office Staff Rating:

Star Rating for Overall Office Staff Rating:

Overall Doctor Rating?

Star Rating for Overall Doctor Rating?

Overall Rating:

Overall Comments: *Required

By clicking "Yes" you acknowledge you have read and agree to our . This grants us permission to publish your survey on our website and social media channels and send you a one time SMS text message. *Required

Yes No

Terms of Service

Authorization and Release of Testimonial Information

I understand my photo or video testimonial (the "Testimonial") made on behalf of Innovation Dental (hereinafter called "The Practice") may be used in connection with publicizing and promoting The Practice. I authorize The Practice to use my name, brief biographical information, and the Testimonial as defined on this form.

I hereby irrevocably authorize The Practice to copy, exhibit, publish or distribute the Testimonial for purposes of publicizing The Practice’s services or for any other lawful purpose. These statements may be used in printed publications, multimedia presentations, on websites, social media channels or in any other distribution media. I agree that I will make no monetary or other claim against The Practice for the use of the statement.

In addition, I waive any right to inspect or approve the finished product, including written copy, wherein my testimonial appears.

I hereby hold harmless and release The Practice from all claims, demands and causes of action which I, my heirs, representatives, executors, administrators or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

Data Privacy

PBHS and its Third Party Providers will have the right to collect, extract, compile, synthesize, and analyze data and information resulting from or relating to the use or operation of the services under this Agreement (“Service Data”). Any Service Data collected by PBHS or any Third Party Provider will be owned by the party collecting the Service Data and may be used by that party for any lawful business purpose without a duty of accounting to you subject to the then current privacy policy applicable to the services under this Agreement. You consent to the use and disclosure of personally identifiable and other data and information as described in this Agreement and in the then-current privacy policy applicable to the services provided under this Agreement (“Privacy Policy”).

Indemnification

You agree to and hereby indemnify, defend, and hold harmless PBHS, its Third Party Providers and their respective affiliates, employees, agents, contractors, assigns, licensees, and successors in interest (“Indemnified Parties”) from any and all claims, losses, liabilities, damages, fees, expenses, and costs (including attorneys’ fees, court costs, damage awards, and settlement amounts) that result from or relate to any claim or allegation against any Indemnified Party arising from you accessing or using the services provided under this Agreement (including any Third Party Services) or from any email or other communication generated or sent through such services or any content contained therein, whether or not in breach of this Agreement.

Messaging Program

PBHS offers subscription text message programs. Customers may ask their agent to enroll them in a text message alert program. Once enrolled in SMS texting services, you will have an opportunity to confirm or decline the service via a reply to an initial text message you receive. By agreeing to these terms of service, you are confirming a subscription to this text message program. Message frequency varies.

PBHS does not have a separate charge for this service; however, message and data rates may apply from your mobile carrier. Subject to the terms and conditions of your mobile carrier, you may receive text messages sent to your mobile phone. Participation in the programs on this short code is standard rated.

By providing your consent to participate in this program, you approve any such charges from your mobile carrier. Charges for text messages may appear on your mobile phone bill or be deducted from your prepaid balance. PBHS reserves the right to terminate this SMS service, in whole or in part, at any time without notice. The information in any message may be subject to certain time lags and/or delays. You are responsible for managing the types of SMS texts you receive.

Privacy Contact Information

If you have any questions, concerns, or comments about our privacy policy you may contact us using the information below:

By e-mail: [email protected]
By Phone: 1-888-840-0739

We reserve the right to make changes to this policy. Any changes to this policy will be posted.