Release of Information - Edina

_2017 Doctor Referral

Patient Authorization for Release of Information

Date:

I herby authorize the release of my Child(ren)s Information:

Child's Name:

Date of Birth:

Child's Name:

Date of Birth:

Child's Name:

Date of Birth:

Child's Name:

Date of Birth:

Dental Records to Dr. :

* Dental Office E-Mail Address: (Required)

Date of Appointment:

Or

Please forward to my home email.

* Home Email Address: (Required)

Reason for Transfer:

Cancel all Future Appointments? Yes No

Parent or Guardian Name:

Address:

Signature:

I understand that Dentistry for Children will provide one copy of these records at no charge. If for any reason more than one copy of x-rays is needed; there will be a duplication fee.

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