Authorization to Share Private Patient Information
Patient Name:
*
(Please Check All Pertinent Boxes):
*
Please check atleast one field
Treatment Information
Financial Information
Appointment Information
ALL OF THE ABOVE
Name:
Cell Phone:
I give authorization to Gwen Cohen, DDS, to share the following information:
Information May Be Shared With:
*
Relationship:
*
Phone Number:
*
Signature
*
Date
*