I acknowledge that by submitting this form, I am providing The Mugford Center with personal information that may be used to contact me regarding my dental care. This information will be handled in accordance with our Notice of Privacy Practices and applicable privacy laws. This form is not intended for urgent medical communications.

Privacy & Communication Consent

By completing and submitting this form, you consent to The Mugford Center contacting you by phone, email, or text message regarding your inquiry or appointment request. Standard message and data rates may apply for text communications.

The information you provide will be used solely to respond to your inquiry and coordinate your care. We do not sell your personal information. Your information is protected under HIPAA and our Notice of Privacy Practices, available at mugfordcenter.com/notice-of-privacy-practices.

This form is not monitored for emergency communications. If you are experiencing a dental emergency, please call us directly at (410) 721-7801.