backbaydentalnh.com - Release of Records

backbaydentalnh.com - Release of Records

RELEASE OF RECORDS
I, (Name)

First NameLast Name
DOB:

MonthDayYear
Date
Authorize:
To Disclose to:

Back Bay Dental
51 Mill Street, Suite 2
Wolfeboro, NH 03894

Telephone (603) 569-1554
backbaydentalnh@gmail.com
Patient Signature:
Date:

MonthDayYear
Date
OR
Parent/Legal Guardian/Representative Signature:
Date:
Should be Empty: