750 Central Avenue Suite K, Dover, New Hampshire 03820 | 603-743-6000 Personal Health Information Disclosure Agreement I, do hereby grant permission for Dover Pediatric Dentistry to disclose· my personal health information to the following personal representatives: spouse, sibling, parent, child, friend, etc Information to be disclosed (please check): Appointment dates and times Treatment plans and referrals Financial and billing information Any other pertinent dental health information related to treatment at this office. None of the above I understand that this permission will remain in effect unless a written cancellation has been provided to Dover Pediatric Dentistry & Orthodontics, PLLC. Name of Parent/Guardian Parent/Guardian Signature Clear Date / Month / Day Year Date Preview PDF Submit Should be Empty:
