shorttdental.com - Authorization to Release Patient Information (South Lyon)

AUTHORIZATION TO RELEASE PATIENT INFORMATION
PATIENT NAME:
D.O.B:

MonthDayYear
Date
ADDITIONAL FAMILY MEMBERS/D.O.B:
I authorize Name to release my dental x-rays to the office listed below:

SHORTT DENTISTRY

12756 10 Mile Rd

South Lyon, MI 48178

P-(248) 437-8189

EMAIL: info@shorttdental.com
Please upload any current x-rays

Cancelof
BITEWINGS:
PANO/FMX:
Patient(s)/Guardian Signature

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Date

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Date
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