HTML Preview Dental Medical Records Release Form page number 1.
Medical Release Form
Patient Name:_________________________ Date of Birth: ____/____/____
I, ___________________________________, hereby authorize the doctor and staff of
Patient's Name (or Parent/Legal Guardian)
Eastland Family Dental to release records concerning my dental health. I understand that
the specific type of information disclosed may include a detailed report of examinations,
treatment provided, x-rays and other records that pertain to my dental information.
Reason for Leaving Eastland Family Dental:_________________________________
_____________________________________________________________________________
Please select one:
_____ 1. Records given directly to me (or parent/guardian, if patient is minor)
_____ 2. Records to be sent to other dental office (complete below)
Name of Dental Practice/Dentist: ________________________________________
Address: ________________________________________________________________
Telephone Number: _____________________________________________________
Email Address: __________________________________________________________
Effective Date of Authorization:
This authorization is effective through ___/___/___ until I cancel this consent. I understand
that the I may revoke or terminate this authorization by submitting a request in writing to:
Eastland Family Dental 19401 E. 40 Hwy., Ste. 180 Independence, MO 64055
PRINT Patient Name: ______________________________________________________
SIGN Patient Name: _______________________________________________________
(If child, signature of Parent or Legal Guardian) Date: ___/___/___
Signature of EFD Witness:____________________________________________________
Date: ___/___/___