Consent to discuss treatment in Needham, MA

Consent to discuss treatment

Patient Name*

First Last

Consent

The HIPPA privacy law requires that we are only authorized to communicate with patients themselves, insurance providers and primary care doctors, unless we have authorization in writing by the patient to communicate with another individual on their behalf.

I herby give permission to discuss all aspects of my dental treatment to the individual listed below:

Name*

First Last

Relationship to patient:

Date*

Signature

Please make sure to click SUBMIT