Authorization to Release Information

Authorization to Release Information
Your Name *

First Name Last Name
Date *

Month Day Year
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:
Name
Relationship
Name
Relationship
Name
Relationship
Name
Relationship
Signed *

Clear
Date *

Month Day Year
Date
Are you assigning a Dental Healthcare Proxy? *

Yes No
Parent/Legal Guardian
Assigned Legal Proxy
Name of Individuals
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.
Signature

Clear
Legal relationship to patient
Should be Empty: