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*
(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: