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5280 Route 309, Center Valley, PA 18034
610-282-1278
M: 9am-5pm | T: 7am-7pm | W: 9am-5pm | TH: 7am-7pm | F: 9am-1pm
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Cirocco Dental Center
Center Valley Oral Health & Cosmetic Dentistry
About
Why Choose Cirocco Dental Center
Meet Dr. Cirocco
Meet Our Staff
Patient Testimonials
Our Technology
Patient Info
Patient Testimonials
New Patients
Oral Surgery Post Care Instructions
Forms
Pricing
Insurances Accepted
Smile Healthy Plan
Our Services
Emergency Dental Services
Fillings
Crowns
Extractions
Dental Hygiene
Gum Disease & Gum Health
Scaling & Root Planing
Dentures & Partials
Dental Implants
Root Canals & Endodontic Treatments
Teeth Whitening & Bleaching
Teeth Grinding & Sleep
Treatment For TMJ
Reveal Clear Aligners
Promotions
Current Promotions
Referral Program
Contact
Book an Appt.
About
Why Choose Cirocco Dental Center
Meet Dr. Cirocco
Meet Our Staff
Patient Testimonials
Our Technology
Patient Info
Patient Testimonials
New Patients
Oral Surgery Post Care Instructions
Forms
Pricing
Insurances Accepted
Smile Healthy Plan
Our Services
Emergency Dental Services
Fillings
Crowns
Extractions
Dental Hygiene
Gum Disease & Gum Health
Scaling & Root Planing
Dentures & Partials
Dental Implants
Root Canals & Endodontic Treatments
Teeth Whitening & Bleaching
Teeth Grinding & Sleep
Treatment For TMJ
Reveal Clear Aligners
Promotions
Current Promotions
Referral Program
Contact
Emergency Contact and Authorization for Release of Health Information Form
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Emergency Contact and Authorization for Release of Health Information
"
*
" indicates required fields
Patient Information
Patient's Name
*
First
Last
Patient's Date of Birth
*
MM slash DD slash YYYY
Emergency Contact Information
Emergency Contact's Name
*
First
Last
Relationship
*
Phone
*
Address
*
Street Address
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Authorization for Release of Health Information
Many of our patients allow family members such as their spouse, parents or others to obtain dental or billing information. Under the requirements of HIPAA we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your dental or billing information released to family members you must sign this form. Submitting this form will only give information to family members indicated below.
I authorize Cirocco Dental Center to release my medical and/or billing information to the following individual(s):
Name
First
Last
Relationship
Name
First
Last
Relationship
Name
First
Last
Relationship
My Information and Consent
Name
*
First
Last
Email
*
Enter Email
Confirm Email
Phone
*
Consent
*
I AGREE. By clicking here and submitting this form, I agree that I have had the opportunity to read and understand this form and ask questions.
Email
This field is for validation purposes and should be left unchanged.
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