You may refer patients to our office by filling out our secure, HIPAA-Compliant Online Referral Form. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. The security and privacy of patient data is one of our primary concerns and we have taken every precaution to protect it.
Please note: the 100MB limit applies to each individual file. If needed, break larger files (such as zip folders) into smaller uploads to stay within this limit.
Authorization and Release of Testimonial Information
I understand my photo or video testimonial (the “Testimonial”) made on behalf of Bergen Oral & Maxillofacial Surgery (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 applyfrom 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:
We reserve the right to make changes to this policy. Any changes to this policy will be posted.
REQUEST AN APPOINTMENT
The first step towards a beautiful, healthy smile is to schedule an appointment. Please contact our office by phone or complete the appointment request form below. Our scheduling coordinator will contact you to confirm your appointment.
