Request for Release of Information
Location
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Northland
Dorchester
Location and Name
Patient Name
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First Name
Middle Name
Last Name
Birthday
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Month
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Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State
Zip / APT#
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I hereby authorize Living Wellness Dental to obtain the information or records from the below practice.
Mention the record holder practice name in the below box
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Please forward X-rays to "northland@lwdental.ca"
for the following patients (Click + add more)
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Information being requested
Bitewings
Panorex
Probing Charts
PA’s
Study Models
Full Chart
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This is to certify that I consent to the dental procedures agreed to be necessary or advisable for myself, or my child / legal dependent, including the use of local anesthetic or other drugs as indicated. I understand that there are no guarantees that the procedures agreed to be necessary will resolve all or any of the described symptoms. I will assume responsibility for fees associated with those procedures, and I consent to the collection, use and disclosure of my personal information as set out above.
Signature
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Name
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First Name
Last Name
Date
*
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Month
-
Day
Year
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