Patient Request for Release of Dental Records
Patient Name:
DOB:
-
Month
-
Day
Year
Date
Information to be released from:
Doctor name:
Address:
Phone number
Format: (000) 000-0000.
Information to be released to:
Kimberly Foon, D.D.S.
Grant R. Willcox, D.D.S., Inc
200 So. El Molino Ave Suite 3
Pasadena, CA 91101
626-449-2996
Fax 626-449-3431
info@drfoon.com
Patient Consent:
I, (patient or guardian)
give authorization to release my dental x-rays for continued treatment.
Signature of patient or Personal Representative
Date:
-
Month
-
Day
Year
Date
Printed Name of Patient or Personal Representative
Contact Phone #:
Format: (000) 000-0000.
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Submit
Should be Empty: