Patient Communication Form - Portland Smiles

Patient's Legal Name*

First Middle Last

Parent(s) / Legal Guardian(s) if under 18

Patient date of birth*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Preferred Phone Number

Phone Preference*

Home
Cell
Work

Phone Number*

Okay to leave message?*

Yes
No

Okay to leave extended message?*

Extended messages may contain dental and/or prescription information.

Yes
No

Preferred email

Email Address:*

Okay to leave message?*

Yes
No

Okay to leave extended message?*

Extended messages may contain dental and/or prescription information.

Yes
No

Communication 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 below

Name

Please 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*

Phone

This field is for validation purposes and should be left unchanged.