Back
Authorization to Release Dental Records and Information
I hearby release Dr Houthoofd and her employees from all provisions of the law prohibiting his/her dental office from disclosing any dental records. This includes, but is not limited to radiographs (xray fils) and reports for:
First Name
Last Name
Date Of Birth
Reason for Transfer:
Please release my information to the following dental office:
Office Name
Office Address
Phone
Email
Patient/Legal Guardian Signature
Sign Here
×
Signature Pad
Date
Back
Next
Back
Next
Submit
Done