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Call: 828 684 1633
600 Julian Lane, Suite 610, Arden, NC 28704
Dentist Asheville, Cosmetic Dentist Asheville, Porcelain Veneers Asheville NC, Asheville Dentist
Dentist Asheville - Working Hours Office Hours
Monday-Thursday
8:30AM to 5:00PM
Fridays
9:00AM to 5:00PM
Dentist Asheville
More Than A Mouthful

"Dr. Chris Port, Asheville esthetic dentist and smile rejuvenator, recently signed a publishing deal with CelebrityPress, a leading health book publishing company along with other leading dental professionals from across the country to release the book, "More Than A Mouthful."

Press Release
Purchase this bookDentist Asheville
Dentist Asheville - FOY Logo
Our practice is trained in The Denture Fountain of Youth™ technique. Learn more about how The Denture Fountain of Youth™ work, their costs, and why they may be the right tooth replacement for you.

Request for Release of Dental/Medical Records

Print blank form to fill by hand
Please note that it is important to fill in all the fields before submitting. Thank you.

Section A: Patient giving consent
*Name :
 *Last name

 Mid name

 *First name
*Home address :
City
State
Zip
APT#
*Email address :
Social security# :
*Telephone Home : ()--
Cell phone# : ()--

Section B: To the patient - please read the following statements carefully

Purpose of consent: By signing this form, you will consent to our use and disclosure of your protected health info. mation to carry out treatment, ayment activities, and healthcare operations.

Notice of privacy practices: You have the right to read our Notice of privacy practices before you decide whether to sign this consent. Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your protected health information and of other important matters about your protected health information. A copy of out Notice accompanies this consent. We encourage you to read it carefully and completely before signing this consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices we will issue a revised Notice of privacy practices. Which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

Contact person : Email address :
Telephone Home : ()--
Fax # : ()--
Address :
City State
Zip
APT#

Right to revoke: you will have the right to revoke this consent at any time giving us written notice of your revocation submitted to the Contact person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation and that we may decline to treat you or to continue treating you if you revoke this consent.

Signature

I, , have had full opportunity to read and consider the contents of this consent form and your Notice of privacy practices. I understand that, by signing this consent form. I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.

I consent to making of videotapes, photographs, and x-rays before, during, and after treatment, and to use the same by the doctor in scientific papers or demonstrations.

*Signature :
Date :

If this consent is signed by a personal representative on behalf of the patient, complete the following:
Personal representative’s name
Relationship to patient