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 the named doctor or health care provider to release the information specified to the organization, agency, or individual named on this request. I understand that the information to be released includes information regarding the following condition(s):

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

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Date: