Lasalle Dental Information Release Consent (Check good to go)

Previous Dentist
Dental Practice Name
Practice Location
Patient's Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Responsible Party
Responsible Party's Name

First NameMiddle NameLast Name
To

{previousDentist18}

{dentalPractice}

{practiceLocation}

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

Dr. Karine Carpentier

Lasalle Dental Clinic

1001 Lasalle Blvd Unit 1,

Sudbury, ON P3A 1Y1

Please send digital x-rays to drkarinecarpentier@live.ca
I release you from all legal responsibility or liability that may arise from this authorization.
Patient's Signature
Patient's Name

First NameMiddle NameLast Name
Responsible Party's Signature
Responsible Party's Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: