clearcareperio.com - Dental Record Release Form

Dental Record Release Form
I (Patient's Name) * hereby authorize Dr. (Former Dentist's Name)* to provide Dr. (New Dentist's Name)*
With copies of my dental records with respect to any dental care and treatment that I have received.

I understand that the specific type of information to be disclosed includes a detailed report of examinations, treatment provided, x-rays, and all other records which pertain to me.

This consent is effective until such date as I can cancel this consent. I understand that the information obtained as a result of this consent may be used after the cancellation date.
Signature of patient, parent or guardian*

Clear
Printed name of patient, parent or guardian*

First NameLast Name
Date*

MonthDayYear
Date
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