Willow Point Dental P.C.

*Patient Name :

Last name

Mid name

First name

*Address:

				City
State		Zip		APT#

*Phone Number:

()- -

Birthday :

HIPAA Privacy Permission

By signing this form, I give Willow Point Dental permission to disclose my Protected Health Information to the individuals listed below. The information that Willow Point Dental may disclose is limited to the information directly related to that person's involvement in my dental care or payment of my dental care.

Name	Phone Number	Relationship
	()- -
	()- -
	()- -
	()- -

*Signature :		Date :
(Your digital signature (full name) is as legally binding as a physical signature.)