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Authorization to Release Protected Health Information (PHI)
First Name
Last Name
Date Of Birth
If there is anyone that you would like to give us permission to speak with regarding your dental care or account (such as a parent or spouse), please indicate below:
I authorize PureCare Dental of Bend to speak to the following people, in person or by telephone:
Name:
Relationship:
Phone:
Name:
Relationship:
Phone:
Patient/Legal Guardian Signature
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