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Mon. Jun 15th, 2026
Moss Dental Group
Affordable Gentle Dentalcare for the entire Family
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Confirmation form
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Which Office are you submitting for?
*
JDA
TVD
GHD
SDA
WVD
ECD
Please select the abbreviated form of your office name. EX: JDA (Jonestown Dental Associates)
Would you like the Kiosk Checking Link regarding Patient Forms (New/Existing) to be sent out to paitents automatic?
*
YES
NO
If the answer above is YES, please enter the number of days prior the Kiosk Check-in Link should be txt/emailed to the patient. If your answer was no, please enter a value of 0.
*
Do you feel the current default Confirmation message is sufficient?
*
YES
NO
Current Default Message: (Name of office): Reply C to confirm {{CustomerFirstName}}’s appt on {{AppointmentDateTime}}. Can’t make it? Call (office #)
If Not, What would you like it to say. (There is a 160 Character limit, spaces count as characters as well)
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