• Authorization to Release Information

  •  /  /
    Pick a Date
  • I, {yourName}, give my permission to Natick Dental Partners and staff to discuss treatment provided and treatment recommended with the perons listed below until such time as I notify Natick Dental Partners and staff in writing that I am rescinding this authorization:

  • Clear
  •  /  /
    Pick a Date
  • I, {parentlegalGuardian}, Parent or legal guardian, authorize {assignedLegal}

    to consent to treatment for all dental Procedures for {nameOf} (name/names of

    children). This proxy shall remain in force until such time as I rescind it.

  • Clear
  •  
  • Should be Empty: