www.ampsmiles.com- Authorization to Release Dental Records

Authorization to Release Dental Records
Patient Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number
Please enter a valid phone number.
Email
example@example.com
I authorize the following provider or facility to release my dental records:
Provider/Facility Name
Phone Number (if known)
Please enter a valid phone number.
Fax Number (if known)
Release To:
Amp Orthodontics & Kids Dental

6300 Amp Dr, Clemmons, NC 27012
Fax: 336-999-0022
Email: Hello@ampsmiles.com
Records to be Released (select one)

X-rays only (e.g., bitewings, panoramic, cephalometric)All dental records (includes exams, treatment notes, x-rays, etc.)Other
If "Other" Please Explain
Authorization Terms:
I understand that this authorization is voluntary. I may revoke this authorization at any time by submitting a written request, except to the extent that action has already been taken based on it. This authorization will expire one year from the date signed unless otherwise specified.
Patient or Legal Guardian Signature:
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Authorization to Release Dental Records