Consent to Release Dental Records

Consent to Release Dental Records
I,

First NameLast Name
authorize
Name of previous dental care provider
to disclose the following information:
1. Recent Bitewing X-rays
2. Peri-apical X-rays
3. Panorex
4. Date of last recall exam and cleaning appointment
OR,
Enter the name of the person for whom you wish the release of their health/dental information(and for whom you are the substitute decision-maker).

First NameLast Name
Consisting of their:
1. Recent Bitewing X-rays
2. Peri-apical X-rays
3. Panorex
4. Date of last recall and cleaning appointment
to Thamesford Family Dental, 249 Dundas St West, PO Box 100, Thamesford, ON, N0M2M0.

Email : ThamesfordFamilyDental@gmail.com

I understand the purpose of disclosing this personal health/dental information to the person noted above.
My Name:

First NameLast Name
Signature

Clear
Today's date:

MonthDayYear
Date
Should be Empty: