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GO Orthodontics Tampa (the “Practice”) understands and appreciates the important role that social media plays in a providing feedback on the quality of the services that the Practice provides before, during, and after you/your child’s treatment. However, as a dental practice we are limited in our ability to publicly address the feedback that is published on social media due to patient confidentiality laws. In an effort to ensure that we receive accurate, fair and honest feedback from you, and to prevent the publishing of false and or inaccurate content in any form and in any medium, the Practice has developed this policy to provide a process to reasonably and timely address your concerns, complaints, or other issues without resorting to social media.
By initialing below and authorizing the Practice to treat you/your child, you agree that you or anyone on your behalf, will not post any inaccurate and/or negative review, criticism, complaint, or comment about the Practice and/or any of its dentists or staff members without first notifying the Practice directly, by phone or email, of your concern, criticism, complaint, or other issue and allowing the Practice a reasonable period of time not to exceed 30 days from the date of service at issue to directly address your concern, complaint, or other issue. Such services to which this policy applies include, but are not limited to, billing issues, medication requested, consultation issues, x-ray or MRI testing, clinical, administrative procedures, treatments, and/or personnel issues relating to the Practice’s dentists and/or staff members.
If you violate the terms of this policy, then you have forty-eight (48) hours to retract your review, criticism, complaint and/or comment from the date of posting. In the event that you do not retract your review, criticism, complaint and/or comment within such time period, in whole or in part, the Practice hereby reserves the right to pursue any and all legal and equitable remedies available to it under applicable law, including, but not limited to, terminating your/your child as a patient of the Practice. You agree to assume all legal costs arising, and the fair compensation for damages no limited to the reputation and/or loss of income of the Practice. You also agree to assume all costs and fees associated with the termination of your / your child’s treatment with us and the continuation of the remaining treatment with a new provider.
For the avoidance of doubt, and due to the rapidly expanding world of electronic communication, social media can mean many things. As referenced in this policy, social media includes all means of communication or posting information or content of any sort on the Internet, including to your or to someone else’s blog, journal or diary, personal website, social networking or affinity website, web bulletin board or a chat room, as well as any other form of electronic communication.
I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION. I grant authority to the Doctor and Staff to perform all procedures and treatments in my best interest. I authorize the Orthodontist to share treatment information with collaborating dentists and surgeons when appropriate. I authorize the Orthodontist to submit treatment information pertinent to this patient to the Insurance Company for billing purposes only. I understand that, when appropriate, Credit Bureau reports may be obtained.
GO Orthodontics Tampa may use your orthodontic records for educational and promotional purposes. I know this is in the Consent form, but it allows us to use their photos, etc. for teaching purposes even if they do not start treatment.
Office Use Only:
Forms have been received and reviewed by the doctor: