AUTHORIZATION TO RELEASE
DENTAL INFORMATION

The authorization of this form does NOT authorize the release of information other than the terms specifically described below.

Patients Name:

Date of Birth

Patients Name:

Date of Birth

Patients Name:

Date of Birth

Patients Name:

Date of Birth

Release To:

Email Address:

Fax Number:

I request and authorize (authorized party) to release the information specified to the organization, agency or individual named on this request.

Information Requested:

*Limited to treatment dates and for

Copy of complete dental chart condition described below:

Copy of dental x-rays

All treatment rendered

Other (e.g.models-describe)

Purpose or need for which information is to be used:

Transfer of Records

Second Opinion

Parent / Guardian

Relationship to Patient(s)

Signature

Draw your signature in the box below with your mouse or cursor.

Date: