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Willow Point Dental P.C.

  Last name

  Mid name

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