Consent to Share Confidential Dental Information
Kimberly Foon, D.D.S.
Grant R Willcox, D.D.S., Inc
200 S. El Molino Ave Suite #3
Pasadena, CA 91101
info@drfoon.com
(626) 449-2996
Patient's Legal Name:
Birth Date:
-
Month
-
Day
Year
Date
I HEREBY AUTHORIZE KIMBERLY FOON D.D.S., INC. TO SHARE:
My appointment dates, times, and reasons for the visits
Referral to another dental specialist
Recommended treatment
Medications and prescriptions
Cost of treatment
WITH THE FOLLOWING PEOPLE:
Full Name:
Relationship:
Full Name:
Relationship:
Full Name:
Relationship:
Signature:
Date:
-
Month
-
Day
Year
Date
I understand that I can cancel this consent at any time (In person signature required), but that cancelling it will not affect any information that has already been released.
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