Contact Release Form - Legacy Dental Franklin

What is the best number to reach you?

Can the Legacy Dental Associates staff leave messages regarding your medical or dental-related information, such as appointments or dental/medical status, on this number?

Yes
No

Do you give Legacy Dental Associates consent to look up a list of current medications for your Medical History online through your pharmacy?

Yes
No

If yes, which pharmacy?

messages dental/medical current

Signature:

Clear Signature

Date: