Dr. Cruz - Authorization to Release Dental Information

Authorization To Release Dental Information
To:*
Patient Name:*

First NameMiddle NameLast Name
Fax:*
DOB:

MonthDayYear
Date
SSN:*
I request and authorize the above-named doctor or health care provider to release the information specified below
to the organization, agency or individual named on this request. I understand that the information to be released
includes information regarding the following condition(s):
INFORMATION REQUESTED:

Copy of complete dental chartCopy of dental x-raysAll treatment renderedOthers (e.g. models—describe)Other
DATES COVERED:
*Limited to treatment dates and for condition described below:
PURPOSE OR NEED FOR WHICH INFORMATION IS TO BE USED:

Transfer of RecordsSecond OpinionOther
Patient Signature*

Clear
Patient Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Authorization To Release Dental Information