Release form blank

Request for Release of Records
Date:*

MonthDayYear
Date
I (Patient's Name)*
hereby request and give my permission to Dr. Robert Olson to provide
Dr.*
Address*

Street Address

CityState

Zip Code
any and all information which he/she may request with respect to the orthodontic care of
Patient*
Such records may include medical care and treatment, illness or injury, dental history, medical history, consultation, prescriptions, x-rays, models and copies of all dental records and medical records.

I agree to pay the cost of duplicating any records (N/A). A photocopy of this release will be as effective and valid as the original.
Signature*

Clear
Date Signed*

MonthDayYear
Social Security # N/A
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Signed*

Clear
Date Signed*

MonthDayYear
(Parent, Legal Guardian or Custodian of the Patient, if appropriate)
Print Name*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
©American Association of Orthodontists 2019 Reviewed 2018
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