Confidential Information

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  • EMERGENCY CONTACT INFORMATION

  • PERSON WE MAY CONTACT IN CASE OF AN EMERGENCY (OTHER THAN YOUR FAMILY HOME)

  • REQUEST FOR CONFIDENTIAL COMMUNICATION

  • AS MY DENTAL CARE PROVIDER, YOU MAY DO THE FOLLOWING WITH MY PERMISSION:

  • INSURANCE AND FINANCIAL INFORMATION

  • RELEASE INFORMATION

  • YOU MAY DISCUSS MY HEALTHCARE WITH

  • CONFIRMATIONS

  • DO YOU PREFER A CONFIRMATION CALL

  • ASSIGNMENT & RELEASE

  • I hereby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due and authorize the dentists to release any information for this claim. I authorize that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by this dental office, I am obligated to pay said office in accordance with its credit terms and policy. I consent to making of videotapes, photographs, and x-rays before, during, and after treatment, and to use the same by the doctor in scientific papers or demonstrations. I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.

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