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
2 digit month, 2 digit day, 4 digit yearDate
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.
Signature
Should be Empty: