Release of Information Form

_2017 Doctor Referral

PATIENT AUTHORIZATION FOR RELEASE OF INFORMATION

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

Or

Please forward to my home email.
Cancel all Future Appointments?

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.



Security Measure