Confidential Information

I. Confidential Information Questionnaire

II. Emergency Contact Information

Person we may contact in case of an emergency

III. Request For Confidential Communication

As my dental care provider, you may do the following with my permission:

IV. Dental Insurance And Financial Information






V. Release Information

You may discuss my healthcare with:

VI. Assignment & Release

I authorize release, to my benefits plan administrator and CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named Dentist. This authorization shall continue in effect until the undersigned revokes the same.

All appointments scheduled are considered confirmed at the time of booking. We will remind you of an upcoming appointment via email, text, or personal call.

I hereby authorize the making of videotapes, photographs, and x-rays of my dental care treatment (collectively “My Images”), and my dentist’s use of My Images in scientific papers, demonstrations and/or presentations without compensation to me.