BALA KIDS DENTISTRY AUTHORIZATION TO RELEASE DENTAL RECORDS

Authorization To Release Dental Records
Patient Name:*

First NameLast Name
Patient Date of Birth:*

MonthDayYear
Date
DISCLOSE TO:*

SelfDental ProviderOther
DELIVERY OPTIONS:*

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

I hearby authorize:Other
SEND RECORDS TO:

Send records:Other
ADDRESS TO SEND RECORDS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Fax Number

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

Copy of dental recordsDental x-raysOther
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

MonthDayYear
Date
Parent/Guardian Name*

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

Authorization To Release Dental Records