Patient Communication Form Patient's Legal Name* First Middle Last Parent(s) / Legal Guardian(s)Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone ContactsPhone Preference* Home Cell Work Phone Number*Okay to leave message?*YesNoOkay to leave extended message?*Extended messages may contain dental and/or prescription information.YesNoEmail ContactsEmail Address 1* Okay to leave message?*YesNoOkay to leave extended message?*Extended messages may contain dental and/or prescription information.YesNoEmail Address 2 Okay to leave message?YesNoOkay to leave extended message?Extended messages may contain dental and/or prescription information.YesNoText Message ContactsCell PhoneOkay to leave message?YesNoOkay to leave extended message?Extended messages may contain dental and/or prescription information.YesNoCommunication Permissions*I do not want any information about my healthcare communicated to family members/caregivers.I give Portland Smiles permission to verbally communicate to family members/caregivers listed belowNameNameNamePlease check the box next to the specific information that may be verbally communicated to the individual(s) listed above: Treatment information Billing Prescription Request Referral Request Appointment Information This authorization will be updated every 12 months. I have the right to revoke this authorization in writing at any time. Revocation will not cover information release prior to that date.Patient/Parent/Legal Guardian Signature*Date* Date Format: MM slash DD slash YYYY