AUTHORIZATION TO RELEASE RECORDS

AUTHORIZATION TO RELEASE RECORDS
I hereby authorize the release of all my dental x-rays and dental records and request that they be transferred to:

Dr. Gregory Wang, DDS

22010 17th Ave SE, Suite B

Bothell, WA 98021

Tel : 425-481-8571

Fax: 425-368-3215

Email: office@sunshinedentalcare.net
Name of Patient
Date of Birth

MonthDayYear
Patient Signature

Clear
(Parent or legal guardian if patient is minor, power of attorney must be represented, if necessary
Date

MonthDayYear
Please include previous dental office information below:
Office Name
Practice Address
Practice Tel
Practice Email
example@example.com
Should be Empty: