Seaman Family Dentistry Release
Privacy Release for Family Members

This form allows us to discuss your dental/medical information with specified family members or other individuals you wish to have access to your information.
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  • Privacy Realease Authorization:

    I give permission to the staff of Seaman Family Dentistry, PA to discuss, or privide written details regarding, my dental care, dental needs, and insurance/billing information with individual(s) listed below:
  • Verification:

    I understand this authorization will remain valid until I cancel it in writing. I also understand that the combination of my date of birth and the last four digits of my social security number will accepted as my electonic signature, giving Seaman Family Dentistry the above mentioned permissions.
  • Use the last 4 digits of your soc sec # here.