New Patient Registration Forms

AUTHORIZATION TO RELEASE DENTAL/HEALTH CARE INFORMATION TO CHANDLER FAMILY DENTISTRY
I request and authorize the doctor listed below and practice to release dental/health care records on the following patient to Chandler Family Dentistry/Dr. lrina Chandler, DDS, 253 Main Street, Warsaw, Virginia 22572, 804-333-0226.
Patient's Name*
Other Names of Patient
Date of Birth*

MonthDayYear
Doctor's Name*
Name of Practice
Phone
Phone
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
This request and authorization apply to dental/health care records relating to the following treatment and dates of treatment and condition.
This request and authorization apply to all dental/health care information.

YesNo
Other
This authorization expires on (insert date).

MonthDayYear
I may cancel this authorization to the extent allowed by law. If I do, I understand that the doctor or practice may have already released information about me after I gave permission. I know canceling this authorization would not prohibit any release of information by the doctor or practice relying on my original authorization.

There are two ways to cancel this agreement:
- Sign and date a form available from the Doctor or Practice called “Revocation of Authorization for Use and Disclosure of Health Care Information.”
- Write a letter to the Doctor or Practice. If I write a letter, it must say that I want to cancel my authorization to disclose my Health Care Information. I (or my authorized representative) must sign and date the letter.
Once my doctor gives out the information I want to release, I know that my doctor has no control over the information. The individual or organization that I authorized to receive the information might re-disclose it. Federal or state privacy laws may no longer protect the information.

Please acknowledge by signing below.
Signature of Patient or Patient's Authorized Representative*

Clear
Today's Date

MonthDayYear
Relationship or status if signed by parent, legal guardian, personal representative, etc.
Should be Empty:

AUTHORIZATION TO RELEASE DENTAL/HEALTH CARE INFORMATION TO CHANDLER FAMILY DENTISTRY