Dr. James Hart Jr., D.M.D Dr. Terence Lunday, D.M.D. Dr. Susan Kelly, D.M.D Occasionally it is necessary for our office to call a patient regarding appointments, insurance, financial matters, test results, coordinate/discuss referral to another dentist, discuss medication changes, refills, etc. Please list the family members or other persons, if any, whom we may inform, discuss, or leave messages with about your medical/dental condition and your diagnosis. This is only necessary if we cannot reach you. Name: ______________________________________ Relationship:_________________________________ Phone Number(s)_____________________ Name: ______________________________________ Phone: ______________________________________ Number(s) ___________________________ Please print the telephone number where you want to receive calls about your appointments, cancellations, billing information or other health care information. Home-_______ Work___________________________ Cell________ Other___________________________ Can confidential messages (i.e. messages to call the office regarding results or appointments, etc.) be left on your home answering machine or voice mail? YES NO Can we call you at your place of employment if you cannot be reached at home? YES NO Can we send e-mail reminders about your appointments? If so, please list your e-mail address: ____________________________________________________________________________ Patient Name (Print)__________________________________________ Signature: __________________________________________________ Date: ______________________