Release Form | warringtondentalarts

Authorization to Release Dental Information

Please fill out the following form.

First name

Last name

Date of birth

Month

Day

Year

PLEASE FORWARD MY REQUESTED DENTAL INFORMATION TO:

Name of New Dentist or Dental Office:

Email of New Dentist or Dental Office:

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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