Patient Consent to Receive Mail and/ or Telephone Messages in Leesburg & South Riding, VA

Name*
First Middle Last
Do we have your permission to:
Preferred method of contact*
- answering machine
- voice mail
- e-mail
- text
Send a recall appointment reminder to your home*
- Yes
- No
Leave appointment, billing or dental information on you preferred method of contact*
- Yes
- No
I give permission to share appointment, billing or dental information with my dentist, physician or other healthcare professional and the person(s) named below;
Person #1
First Last
Relationship to patient
Person #2
First Last
Relationship to patient
This consent is effective until I revoke or rescind in writing or until the end of orthodontic treatment. Please sign below.*
Date*
MM slash DD slash YYYY
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Name
This field is for validation purposes and should be left unchanged.

"Well managed office with the best care and response. I have never seen such an efficient setup with good results as well."

GOBAL D.

"Everyone is knowledgeable and easy to work. Not to mention that the end result of my kids' teeth is what every parent would want!"

PRAMOD R.

"This is the most well run orthodontist office, or any doctors office frankly, that I have ever experienced. It's very clear why Landsdowne Orthodontics is so busy!"

CATHERINE H.

"I highly recommend Dr. Hukmani. As an adult, I got braces through him. He is thorough and explains what to expect before and after each appointment."

HANNAH B.

"Extremely friendly and efficient office. Always running on time. I highly recommend this office to anyone needing orthodontic care."

MICHELE T.

"Absolutely professional and friendly staff. Dr. Hukmani explained everything regarding treatment and follow up appointments."

RUSS H.

"Dr. Hukmani's demeanor is very sweet, calm natured, and he is thorough in explaining after every single visit. Seriously love it!"

JENNIFER O.

"The staff worked hard to schedule around school and other obligations. Dr. Hukmani was always willing to explain what each step he was doing and why."

LOU S.

"I received excellent personalized care at Lansdowne Orthodontics. The staff is amazing, they are patient, caring, and aways work efficiently."

GENIE L.

"Dr. Hukmani is the best orthodontist my son and I have met. He is extremely professional. Their staff are amazing and always welcoming."

SOLEDAD R.

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