Patient Communication Consent Form

I authorize the following people below who River Ridge Orthodontics may communicate with regarding appointments, treatment or account information for:

Patient First Name:
Patient Last Name:
Full Name:
Relationship to Patient:
Full Name:
Relationship to Patient:
Full Name:
Relationship to Patient:
Full Name:
Relationship to Patient:
E-Signature (Parent's signature if minor):
Date:
Relationship to Patient: