Authorization to Release Dental Information Form

Date of Birth

Date

Patient Name

First NameLast Name

Phone Number

Please enter a valid phone number.

Email

example@example.com

Release Dental Records To

The PatientDental ProviderOther

Delivery Methods

I, the patient, authorize First Name Last Name to pick up my records.

Please upload a photo

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Fax #

Only past five years' record will be disclosed. If you have any specific dates please fill the following date fields.

From

Date

To

Date

Information To Be Disclosed

Treatment PlanRadiology Films/imagesAll Billing RecordsOther

If you have specific instructions or specific information not to be disclosed, please explain them here.

Expiration: The authorization is for one year. If you have any specific dates please fill the following date fields.

From

Date

To

Date

Signature

If the signature other than the patient, please complete following areas. The signature belongs to:

Parent/Legal GuardianNext of Kin / Executor of DeceasedOther

Name

First NameLast Name