Patient Consent Form (age 18 & over)

"*" indicates required fields

Patient’s Legal Name*

First Last

Date of Birth*

Phone Number*

Email*

I give the following individual(s) permission to speak on my behalf. They are allowed access to my billing information and/or medical records (for example: to schedule/cancel appointments, billing questions/payments, request for prescription refill, discuss dental care, etc.). I understand that I can add or remove anyone from this list at any time by filling out another consent form.

Name

Relationship

Type of Access Allowed: Schedule Appointments For How Long?

Name

Relationship

Type of Access Allowed: Schedule Appointments For How Long?

Name

Relationship

Type of Access Allowed: Schedule Appointments For How Long?

Patient Signature*

Date*

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

Office Hours

Monday – Thursday
8:00 AM – 4:30 PM

Stowe Dental Associates

Contact Us

We believe that excellent care begins with open communication.

If you need more information, have any questions, or want to schedule an appointment, please contact us!

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 32 Mountain Road
PO Box 1543
Stowe, VT 05672

 DIRECTIONS

 802.253.7932

 info@stowedentalassociates.com

 Hours: Mon – Thurs: 8:00 AM – 4:30 PM