Authorization to Release Dental Information Form

Authorization to Release Dental Information Form
Date of Birth
MonthDayYear
Date
Patient Name
First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Release Dental Records To
Other
Delivery Methods
Other
I, the patient, authorize First Name Last Name to pick up my records.
Please upload a photo
Cancelof
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
MonthDayYear
Date
To
MonthDayYear
Date
Information To Be Disclosed
Other
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
MonthDayYear
Date
To
MonthDayYear
Date
Date
MonthDayYear
Date
Signature
Clear
If the signature other than the patient, please complete following areas. The signature belongs to:
Other
Name
First NameLast Name
Should be Empty:

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