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By signing below, you understand that we cannot release any information without your written consent. However, this is not your written consent, just an understanding of the privacy (HIPPA) law.
Signature: (Use your mouse or finger to sign your name)
Date:
Responsible Party/Guardian
Birthdate:
Contact Number:
Your email
I approve Resi-Dental to disclose and release my protected health information to the persons listed below:
I authorize Resi-Dental and staff to preform diagnostic services and treatment as necessary for treatment. I authorize of any information regarding my health history, treatment and proposed treatment by Resi-Dental to another dentist or insurance company. In consideration for the professional services rendered by Resi-Dental, I agree to pay in full for the services provided. I grant my permission to contact the Patient or Guardian to discuss matters related to the Patients treatment.
