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Mattson-Hellickson Dental Samuel J Mattson, DDS – James C Mattson, DMD Benjamin B. Hellickson, DDS Release of Verbal Medical/Dental Information Patient Name: Date: Due to patient confidentiality laws, Mattson-Hellickson Dental does not release any information verbally regarding our patients, except directly to the patient. At times, patients may wish to have information on their medical or dental treatment(s), condition(s), lab reports, medications, appointment times, billing questions, etc. discussed with other individuals such as family members or caretakers. Please indicate below any persons with whom you allow us to share information regarding your condition, and their relationship to you. EITHER: I allow Mattson-Hellickson Dental to verbally release any information on my medical condition(s), lab work, medications, appointment times, billing questions and other medical information to the following person(s): Person Relationship Signature: OR: I specifically forbid Mattson-Hellickson Dental to verbally discuss any aspect of my medical or dental condition but anyone but myself. Signature: