Download Printable Version

Authorization for Release of Dental Information

I,

Printed Name

hereby authorize

Printed Dentist Name

to release any and all dental records and radiographs relative to my care to:

Family Dentistry of Caledonia

9021 N. Rodgers Ct

Caledonia, MI 49316

info@famdentcal.com

Reason for request:

Additional family members for whom you are requesting release of information

First Family Member

Second Family Member

Third Family Member

Fourth Family Member

Fifth Family Member

Patient Email

Patient Telephone

Signature of Patient or Responsible Party

Date

Signature of Witness Party

Date

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue