To

{name}

{practiceName}

{practiceLocation}

I authorize the above Dentist to furnish my dental records, including x-rays and
the last record of the requested treatment to:

Hanson Dentistry

2945 Highway 69 North, Suite 301
Val Caron, ON P3N 1N3

Phone#: 705-897-9777 

Please send digital x-rays to: hansonfamilydentistry01@gmail.com
I release you from all legal responsibility or liability that may arise from this
authorization.