Gentle Dental's Notification Policy

    It is Gentle Dental's mission to protect patient privacy and not release confidential information by home telephone, answering machine, work telephone, voice mail, cell phone and/or pager. If an answering machine is reached when returning a call, we do not leave any messages other than appointment reminders. We do not leave information with unauthorized persons.

    If you would like to have information released to someone other than yourself, please complete the following:

    I authorize the staff of Gentle Dental to leave dental information pertaining to my care with the following persons:

    Who may we discuss your financial situation with?

    Your Pharmacy Information

    Use this section to tell your prescriber where you want your prescriptions filled. This will help your prescriber keep track of your pharmacy information.

    Your pharmacy :
    Pharmacy address:
    Pharmacy phone number: