Release of Information

This form is required by our practice to verify we have your permission to release your child’s dental records.

After completion of this form, either mail or bring the form to the office where your child is usually seen. Faxed forms can not be accepted because an original signature is REQUIRED.

Please allow seven to ten business days to process this request.

***Note: this release form must just be signed by the patient if the patient is 18 years of age or older.

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Release of Information (PRINT)

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