EMERGENCY CONTACT INFORMATION
If you would like us to contact someone specific in the event of an emergency, please leave their information below. Please note that this person will not have access to your records unless they are added to the “Authorization to Release Information” below.
CURRENT MEDICAL CARE PROVIDER
Please give us the name of your primary care physician if you have one.
DENTAL INSURANCE PROVIDER
Please give us the details of your current dental insurance. If you have more than one dental insurance please let us know.
ADD ADDITIONAL PEOPLE TO ACCOUNT
AUTHORIZATION TO RELEASE INFORMATION
The following is used to obtain authorization to release information regarding yourself covered under the HIPAA Privacy Act to people other than yourself. Only parents of minors, legal guardians, or individuals listed below will have any access to your status as a patient, medical/dental history, information regarding your dental care, or treatment plans.