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 Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
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 (Sending) Dental Office
Select receiving clinic
Please Select
Parkhill Dentistry
Other
Other Clinic Name
Records to Release
*
Purpose
Signature
*
Date signed
*
-
Month
-
Day
Year
Date
Submit Authorization
Should be Empty: