REQUEST FOR RELEASE OF RECORDS - Orthodontist Arvada
Request for Release of Records
Date:
I (Patient’s Name) hereby request and give my permission to Dr. to provide
Dr.
Address City State/Province Zip Code
any and all information which he/she may request with respect to the orthodontic care of
(Patient) .
Such records may include medical care and treatment, illness or injury, dental history, medical history, consultation, prescriptions, x-rays, models and copies of all dental records and medical records.
I agree to pay the cost of duplicating any records. A photocopy of this release will be as effective and
valid as the original.
Signed _________________________________________________ Date Signed __________________
(Patient )
Social Security # - -
Phone ( ) -
Address City State/Province Zip Code
Signed ______________________________________________________ Date Signed ____________
(Parent, Legal Guardian or Custodian of the Patient, if appropriate)
Phone ( ) -
Address City State/Province Zip Code
................
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