Bluegrass Pediatric Dentistry Release of Records

Release of Records
Child's Name
Date of Birth

MonthDayYear
Date
Parent/Guardian Name
I hereby authorize Bluegrass Pediatric Dentistry to request/release all information and records from/to the following:
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature of Parent/Guardian:

Powered by Jotform SignClear
Date

MonthDayYear
Date
Should be Empty: