Legal Guardian field is required

(Patient/Parent or Legal Guardian)

This field is required

(Medical/Dental/Orthodontic Practice)
(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.

I agree to pay the cost of duplicating any records. A photograph or scanned copy of this release will be as effective and valid as the original.

(Patient)

Signature1 field is required

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

Signature2 field is required

(Street)
(City, State, Zip)

Date field is required