I allow this practice to disclose my Protective Health Information to the following individuals: (This information could include: Name, Diagnosis, Test Results, Images, and Account Information.)

I understand that from time to time it may be necessary for your office to make disclosures of my information in connection with my treatment needs by providing or coordinating treatment details with another dentist or health professional.

治療に関して個人情報を他の歯科医または医療専門医に紹介または相談、検査のための標本提供などの情報を開示することに同意いたします。

Name and Relationship to Patient 氏名・患者様との関係