Release of Records

Release of Records
Patient Name

First NameLast Name
Parent or Guardian Name (type n/a if filling out for self)

First NameLast Name
Patient Date of Birth

MonthDayYear
Date
Dental or medical office requested to share records with Otter Orthodontics
By signing below, I consent that the office above may share mine or my child's medical/dental records in conjunction with my or my child's orthodontic treatment with Otter Orthodontics.
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