EmailMeForm
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.
Patient (Your) Name:
*
First
Last
Date of Birth:
*
MM
/
DD
/
YYYY
Your email address:
*
Confirm
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:
Name of 1st Individual:
*
First
Last
Relationship of 1st Individual:
*
Parent
Legal Guardian
Sibling
Other
Name of 2nd Individual:
First
Last
Relationship of 2nd Individual:
Parent
Legal Guardian
Spouse
Sibling
Other
Name of 3rd Individual:
First
Last
Relationship of 3rd Individual:
Parent
Legal Guardian
Spouse
Sibling
Other
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.
Electronic Signature:
*
Use the last 4 digits of your soc sec # here.
