backcovedental.com - Patient Release Form

AUTHORIZATION TO RELEASE MEDICAL RECORDS
Date:

MonthDayYear
Date
To:
Patient’s Name:
Patient Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please forward any x-rays and other dental records as necessary for the patient above to the office of Dr. Steven S. Shaw. You may email x-rays to the following email address: info@backcovedental.com.

If you have any other questions, please feel free to contact our office at (207) 773-3794. Thank you.
Patient’s signature: (Parent or Guardian)

Clear
Notice: Steven S. Shaw D.M.D., P.C., complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, nationalorigin, sex, or age. If you speak English, the language assistance services are complimentary. (French): Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement.(Spanish) : si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
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AUTHORIZATION TO RELEASE MEDICAL RECORDS