Release of Records

RECORDS TO:

Email Address:

Address:

City:

State:

ZIP:

Phone:

Fax:

RECORDS FROM:

Email Address:

Address:

City:

State:

ZIP:

Phone:

Fax:

Patient Information

Patient Name:

Date of Birth:

Email Address:

Address:

City:

State:

ZIP:

Phone Number:

I authorize the release of dental and medical records relevant to dental treatment or copies of such as the authority to release this information is given below.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Name/Signature (or Guardian):

Date:

Your information will be encrypted.

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