Authorization to Release Dental Info

Patient Name

First Last

Date of Request

Date of Birth

Release records to:

Phone number (of the person to receive records):

Email (of the person to receive records):

Address (of the person to receive records):

I request and authorize TC Orthodontics to release the information specified below to the organization, agency, or individual named in this request.

Information Requested:(Required)

Copy of x-rays

Copy of photographs and x-rays

Purpose or need for which information is to be used:(Required)

Transfer of records

Second opinion

Other

I certify that this request has been made voluntarily and that the information given above is accurate to the best of my knowledge. I understand that I may revoke this authorization at any time, except to the extent that action has already been taken to comply with it. Without my express revocation, this consent will automatically expire upon satisfaction of the need for disclosure.(Required)

Name of patient or legal guardian if under age 18 requesting release:

Signature: