Waiver to discuss treatment 18+

Permission to Verbally Discuss Protected Health Information

For patients 18+
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I give permission to Fischman Orthodontics (Dr. Steven A. Fischman and his staff) to discuss the following medical/dental and financial information about me: *

Scheduling/appointment information Medical/dental information pertaining to my orthodontic treatment Billing/payment information Type option 4 Other
Fischman Orthodontics (Dr. Steven A. Fischman and his staff) have my permission to discuss the above information with:
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Phone type

Home Cell Work
Phone Number
Please enter a valid phone number.
Phone type

Home Cell Work
Email *
example@example.com
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Phone type

Home Cell Work
Phone Number
Please enter a valid phone number.
Phone type

Home Cell Work
Email
example@example.com
I understand that I have the right to revoke my permission at any time except where Fischman Orthodontics has already made disclosures in reliance upon this request. I will notify Fischman Orthodontics in writing if I want to revoke my permission.
Signature *

Clear
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Permission to Verbally Discuss Protected Health Information

Fischman Orthodontics (Dr. Steven A. Fischman and his staff) have my permission to discuss the above information with: