BALA KIDS DENTISTRY AUTHORIZATION TO RELEASE DENTAL RECORDS

Authorization To Release Dental Records
Patient Name: *

First Name Last Name
Patient Date of Birth: *

Month Day Year
Date
DISCLOSE TO: *

Self Dental Provider
DELIVERY OPTIONS: *

Mail Email Fax (Cannot fax x-rays) Pick up
PICK UP (photo ID is required):

I hearby authorize:
SEND RECORDS TO:

Send records:
ADDRESS TO SEND RECORDS:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Fax Number

Area Code Phone Number
Email
example@example.com
When transferring information, we only send records within the last five years.
INFORMATION REQUESTED: *

Copy of dental records Dental x-rays
I hereby authorize Bala Kids Dentistry to provide copies of my dental records with respect to any dental care and treatment that I have received.
Signature of Parent or Legal Guardian

Clear
Date

Month Day Year
Date
Parent/Guardian Name *

First Name Last Name
Cell *
Email Adress *
Relationship to child *
Should be Empty:

Authorization To Release Dental Records