Legal Guardian field is required
This field is required
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.
Signature1 field is required
Signature2 field is required
Date field is required
945 Elliott Ave W#100
Seattle, WA 98119
(206)285-5000/ Fax (206)285-5040