Transfer of Dental Records to 2032 Dentistry

AUTHORIZATION FOR RELEASE OF DENTAL/MEDICAL RECORDS AND RADIOGRAPHS
This note authorizes the transfer of my (and listed family members) dental/medical records to the office of:

2032 Dentistry
Dr. Kathryn Moore
Dr. Sarah Trotter
Email: info@2032Dentistry.com
Fax: 705 743-5680
1. Patient Name

First NameLast Name
2. Patient Name

First NameLast Name
3. Patient Name

First NameLast Name
4. Patient Name

First NameLast Name
5. Patient Name

First NameLast Name
6. Patient Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityProvince

Postal
Current or Previous Dentist and Dental Office
Patient 1 Signature (or signature of parent/legal guardian)
Patient 2 Signature (or signature of parent/legal guardian)
Patient 3 Signature (or signature of parent/legal guardian)
Patient 4 Signature (or signature of parent/legal guardian)
Patient 5 Signature (or signature of parent/legal guardian)
Patient 6 Signature (or signature of parent/legal guardian)
If you are signing on behalf of the patient as a parent or legal guardian, please enter your name and relationship to the patient below

First NameLast Name
Relationship
Relationship to Patient
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

AUTHORIZATION FOR RELEASE OF DENTAL/MEDICAL RECORDS AND RADIOGRAPHS