Internet Consent Form

Consent for Internet Communications

Patient Name:

I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns.

I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.


CALL US AT 908-722-8110



Here at Branchburg Dental, it is our mission to deliver quality dental care to all of our patients, regardless of their insurance status. As dental health professionals, we are aware of the financial burden that proper dental care can place on a family.
We believe it is our responsibility to the community we serve to offer an affordable dental discount plan.


  • Two dental cleanings in a twelve-month period*
  • Two dental exams in a twelve-month period*
  • One emergency exam in a twelve-month period*
  • Annual Oral Cancer Screening
  • All necessary intraoral photographs*
  • All necessary periodontal measurements*
  • All necessary xrays- checkup and emergency appts*
  • One fluoride treatment (adult, 18+)*
  • Two fluoride treatments (child 17 and under)*
  • 15% savings on treatment (some exclusions apply)*

*Procedures above are patient specific based on patients’ needs and age.

*Inquire at office for specific exclusions


  • No annual deductible
    • No annual maximums
    • No preauthorizations required
    • No waiting period or eligibility period for treatment
    • No missing tooth clause restrictions or exclusions for tooth replacement


  • This is an In-Office Patient Membership Club, not dental insurance. It cannot be combined with any other dental insurance or savings plan.
  • This membership is only accepted at Branchburg Dental located at 1069 Route 202 North, Branchburg, NJ.
  • This membership is non-transferrable. Family members cannot be substituted in for another family member.
  • This membership is non-refundable. No refunds will be given if a patient chooses not to take advantage of the benefits.
  • Rates are subjected to change annually.
  • Payments for restorative services are due in full at the time of services are rendered, unless other arrangements have been made prior to treatment.
  • Branchburg Dental LLC reserves the right to refuse treatment and/or terminate a patient’s participation in the membership with thirty days written notice if a patient’s account becomes delinquent or a patient is non-compliant.
  • This membership may be modified, amended, or canceled at any time with a written notice thirty days prior to cancellation. 
  • Membership participants are responsible for scheduling their periodic treatments. Services not utilized by the end of year membership period are not carried over to the following year.