Authorization for Release of Information
Parent Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Dependents and Date of Birth
Release Information to the Following
Dentist Name
Phone Number
Email Address
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Consent
I hereby authorize Dr. Cox and/or Dr. Beck, to release my dental records or copies thereof (including radiographs and photographs where applicable) and those of my dependents. I understand that the release of these confidential records is at the discretion of the treatment dentist.
Signature
Submit Form
Should be Empty: