Authorization To Release Dental Information

The execution of this form does not authorize the release of information other than the terms specifically described below.

Patient Name

Date of Birth

Release To (Office Name)

Release to Dental Office Email

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 Dental X-Rays

PURPOSE OR NEED FOR WHICH INFORMATION IS TO BE USED:

Transfer of RecordsSecond OpinionOther

Other Please Explain

Authorization:

I certify that this request has been made voluntarily and that the information given above is accurate to the best of my knowledge.

Print Name

Person authorized to sign for patient

Authorization To Release Dental Information

Information Requested:

PURPOSE OR NEED FOR WHICH INFORMATION IS TO BE USED:

Authorization:

Use Mouse or Finger to make signature: