This form only needs to be completed if you have had x-rays taken in another dental office in the last 5 years, if we need to obtain implant information, or if you would like us to send your x-rays to another dental office.
I HEREBY AUTHORIZE Type Previous Dental Office name here TO RELEASE MY RECORDS TO CHCCW DENTAL
I HEREBY AUTHORIZE CHCCW DENTAL TO RELEASE MY RECORDS TO Type New Dental Office name here
The authorization will expire on the following date event or condition date of expiry .If I fail to specify a date, this authorization will expire in twelve (12) months.