www.lcdcare.ca - Lake Chaparral Dental Care Release Form

Lake Chaparral Dental Care Release Form
Patient Name*

First NameLast Name
Previous Dental Office Name
Previous Dental Office Phone Number

Area CodePhone Number
I authorize the release of my information, x-rays, and records related to my treatment to Lake Chaparral Dental Care, Dr. Palka Sawhney Sharma Bsc(Hon), DDS
Signature*
Date*

MonthDayYear
Date
EMAIL: admin@lcdcare.ca

Dr. Palka Sawhney Sharma BSc (Hon), DDS202, 10 Chaparral Drive S.E.Calgary, ABT2X 3P1

Phone:403-278-5272 fax: 403-257-55311
Should be Empty: