Endodontic Treatment Communication Authorization Form

Patient Information

Name: _________________________ Date of Birth: _____________ Chart Number: __________________ Date: _____________________

Authorization for Communication

I, _________________________________, authorize [Practice Name] to communicate with me regarding my endodontic treatment, appointments, and related matters through the following methods (please check all that apply):

• Mobile Phone: ________________

  • Voice Messages
  • Text Messages

• Home Phone: _________________

  • Voice Messages
  • Detailed Messages

• Email: ______________________

• Patient Portal

Authorization to Share Information

I authorize the release of my treatment information to:

1. Name: _________________________ Relationship: ____________ Phone: ________________________

2. Name: _________________________ Relationship: ____________ Phone: ________________________

Emergency Contact

Primary Emergency Contact: Name: _________________________ Phone: _________________ Relationship: ___________________

Acknowledgment

I understand that:

• Communication through electronic means may not be secure
• It is my responsibility to update my contact information
• This authorization remains valid until revoked in writing
• I may revoke this authorization at any time

Signature: ______________________ Date: _________________

For Office Use Only Received by: ____________________ Date: _________________