Patient Communication Form Patient's Legal Name* First Middle Last Parent(s) / Legal Guardian(s) Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone ContactsPhone Preference* Home Cell Work Phone Number*Okay to leave message?* Yes No Okay to leave extended message?*Extended messages may contain dental and/or prescription information. Yes No Email ContactsEmail Address 1* Okay to leave message?* Yes No Okay to leave extended message?*Extended messages may contain dental and/or prescription information. Yes No Email Address 2 Okay to leave message? Yes No Okay to leave extended message?Extended messages may contain dental and/or prescription information. Yes No Text Message ContactsCell PhoneOkay to leave message? Yes No Okay to leave extended message?Extended messages may contain dental and/or prescription information. Yes No Communication Permissions* I do not want any information about my healthcare communicated to family members/caregivers. I give Portland Smiles permission to verbally communicate to family members/caregivers listed below Name Name Name Please check the box next to the specific information that may be verbally communicated to the individual(s) listed above: Treatment information Billing Prescription Request Referral Request Appointment Information This authorization will be updated every 12 months. I have the right to revoke this authorization in writing at any time. Revocation will not cover information release prior to that date.Patient/Parent/Legal Guardian Signature* Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged. Δ
