shorttdental.com - Authorization to Release Patient Information (West Branch)

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

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

SHORTT DENTISTRY

720 W. HOUGHTON AVE

WEST BRANCH, MI 48661

P-(989)345-0185

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

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

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