Request for Release of Records

(First and Last Name)

Summit Dental Health

973 NW Saltzman Road

Portland, Oregon 97229

p. (503) 644-­‐7202 f. (503) 627-­‐0602

I understand that all information I hereby authorize to be obtained will be held strictly confidential and cannot be released without my written consent.

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

I understand that this authorization will remain in effect until revoked by me in writing.

I understand that unless otherwise limited by state or federal regulations, and except to the extent that action has been taken which was based on my consent, I may withdraw this consent at any time by submitting my request in writing.