Release form blank

Request for Release of Records
Date: *

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

Street Address

City State

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 *

Month Day Year
Social Security # N/A
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State

Zip Code
Signed *

Clear
Date Signed *

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

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State

Zip Code
©American Association of Orthodontists 2019 Reviewed 2018
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