Authorization for Family Communication

I authorize Nassim F. Olabi, DDS to release the following information about my health care or that of my child(ren):

Please all check that apply

Any and all information

Information necessary to schedule, confirm, cancel or reschedule an appointment

Information about test results

Information about prescriptions

Information about my bill or account

I grant permission to this individual to bring my child to his/her appointment

Other information (please describe)

If other, please describe

This authorization applies to the following individual(s):

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I choose not to authorize any individuals at this time.

I understand that this authorization is valid until revoked by the patient’s parent/legal guardian.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient’s signature or Parent/Legal Guardian if patient is a minor

Date

Your information will be encrypted.

Authorization for Family Communication

This authorization applies to the following individual(s):

Anderson Pediatric Dentistry