Authorization to Release Dental Records | Evergreen Cosmetic Dentistry

Date Information Requested*
Family or Patient's Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Email*
Dentist's Name*
I Hereby Authorize:
First Last
Phone*
Dentist's Name*
To Release My Records To:
First Last
Phone*
Patient/Legal Guardian E-signature*
Please type full name

Please forward xrays and records to: Stephanie@evergreencosmeticdentistry.com