Landvortho Request for Release of Records Form

REQUEST FOR RELEASE OF RECORDS

Legal Guardian field is required

(Patient/Parent or Legal Guardian)

, hereby request and give my permission

This field is required

(Medical/Dental/Orthodontic Practice)

to provide Leone & Vaughn Orthodontics

any and all information requested with respect to the orthodontic care of

(Patient’s name)

Patient’s name field is required

Such records may include medical care and treatment, illness or injury, dental history, medical history, consultation, prescription, xrays, models and copies of all dental records and/or medical records.

A photograph or scanned copy of this release will be as effective and valid as the original.

Signed:

(Patient)

Signature1 field is required

Signed:

(Parent, Legal Guardian or Custodian of the Patient if the Patient is a Minor)

Signature2 field is required

Address: (Street)

(City, State, Zip)

Date Signed:

Date field is required