Request for Release of Records - Cloudinary

Office Name: _______________________________________________

Office Address: _____________________________________________

Office City/State/Zip: _________________________________________

Office Phone Number: ________________________________________

Request for Release of Records

Date: ______________________

I hereby authorize the release of my dental records or copies of such and request that they are

transferred to:

To (Doctor or Hospital):

Address:

City:

State:

Zip:

Patient Name:

Date of Records:

Patient¡¯s Signature:

Powered by TCPDF ()

_____

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download