Emergency Contact and Authorization for Release of Health Information

"*" indicates required fields

Patient Information

Patient's Name*
MM slash DD slash YYYY

Emergency Contact Information

Emergency Contact's Name*
Address*

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
Name
Name

My Information and Consent

Name*
Email*
Consent*
This field is for validation purposes and should be left unchanged.