SES-Records-Release

Patient Records Release
Dear Dr.
We would like to request all clinical notes and x-rays to be sent to our office.
(patient name)

First Name Last Name
Authorization to release Medical Information
I authorize the release of all my medical files and X rays from the Doctor listed below to Smile Esthetics Scottsdale
Previous Doctor's Name
Patient Signature (Custodian Signature if Minor)

Clear
Date

Month Day Year
Date
Should be Empty: