PATIENT AUTHORIZATION FORM

Many of our patients choose to have family members, such as spouses, significant others, parents, or children, contact us to inquire about treatment plans, procedure codes, and financial information. Additionally, family members and caregivers may assist with booking, rescheduling, or canceling appointments. However, in compliance with the Personal Health Information Protection Act (PHIPA), we are unable to share this information with anyone without your explicit consent. If you would like to grant access to family members or caregivers for these purposes, please complete and sign this form.

You have the right to revoke this consent in writing, except where we have already made disclosures based on your prior consent.

I hereby authorize Ottawa Valley Denture Clinic (OVDC) to share my information and communicate with the following individuals regarding my appointments and other related information:

If someone other than yourself will be contacting the office for appointment scheduling, treatment inquiries, payments, insurance matters, or other related issues, please list all individuals who are authorized to receive information or communicate on your behalf (e.g., Spouse, Son/Daughter, Caregiver, etc.)

Name	Relation to Patient

Authorization Regarding Messages and Communication

Please check all that apply.

To ensure that we can confirm your appointments and provide important updates regarding your appointments, treatment plan, or care, our office may need to leave messages. If we are unable to reach you directly by phone, please indicate your preferences below:

I authorize you to leave a detailed message on my home or cell phone.
I authorize you to leave a message with anyone who answers the phone.
Messages may only be left with :

Messages may only be left with:

First Last

Patient Name*

First Last

Patient Signature