Consent For Use And Disclosure Of Health Information - The Rector Dental Group Page 5

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THE RECTOR DENTAL GROUP
AUTHORIZATION TO RELEASE DENTAL NEEDS
Our mission is to be dedicated to protecting the dental health of our patients. We treat healthy
children as well as those with special needs and adults. We are proud to provide dental care to children
and adults of the community. Our office combines the latest dental knowledge and technology together
with care and compassion. We want every patient to have a positive dental experience. Our expert
staff is great in creating this experience. Your commitment along with our excellent care, will allow for
a lifetime of healthy teeth and gums.
_______________________________________________________________________
Patients Name
Date of Birth
It is the policy of my office to not release dental patient information about you, unless it is for patient
care and treatment or payment. Our office is an open concept. We try to the best of our ability to keep
the discussion of patient information to a minimum. If you wish for our dentist and/or office staff to
leave messages for you on your home telephone, message number, answering machine, work
telephone, voice mail, cell phone, or pager, or to any other person, then you must complete the
following:
I authorize The Rector Dental Group or staff to release dental patient information about me by the
following methods and agree it is my responsibility for notifying my dentist or office staff whenever I
want this to change:
We can call your home or cell number if applicable and leave a message if no
answer
Yes___No___
We can call you at work
Yes___No___
We can communicate with other professional offices and/or insurance companies
Concerning patient information
Yes___No___
Are you ok with our open concept practice?
Yes___No___
You may disclose information to my family members and or non-family members. Please list name
and relationship.
NAME
RELATIONSHIP
___________________________________________________________________________________
____________________________
_______________________________________
Patient Signature
Date
___________________________________________________________________________________
Witness
Date

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