Authorization for Release of Dental Records

Authorization for Release of Dental Records

This form authorizes Eglinton West Dental Centre to request and obtain dental records, radiographs, and related personal health information from another dental office, in accordance with the patient’s written instructions provided below.
Patient Information

Primary patient full legal name
Name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Add Family Member
Requesting Dental Office
Clinic name
Receiving Dental Office
Clinic Name
Records to Release
Purpose
Signature
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Patient Information