Over 18 Forms

Authorization to Release Information
Name *

First Name Last Name
Today's 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 persons 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

Fluoride Treatment Form
Name *

First Name Last Name
Today's date *

Month Day Year
Date
Do you give permission for topical Fluoride? *

Yes No
I, {name37} give my permission to have topical Fluoride treatments, I understand that these treatments may not be covered by my dental insurance.
Patient Signature

Clear
I, {name37} do not give my permission to have topical Fluoride treatments.
Patient Signature

Clear
Should be Empty:

Authorization to Release Information