Release Form | warringtondentalarts

Authorization to Release Dental Information

Please fill out the following form.

First name

Last name

Date of birth

Month

Day

Year

Records and radiographs are routinely released directly to the patient.

Patients may then forward them to the provider of their choice. PLEASE FORWARD MY REQUESTED DENTAL INFORMATION TO:

Your Email Address:

Purpose or need for which information is to be used:

If you answered 'other' to the question above, please explain.

I understand that my express consent is required to release any healthcare information relating to my dental care. I hereby consent to the release of the above requested information.

Signature

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Dental Record Release Form