Records Release Form

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Records Release Form
Dear Dr. name* ,
I herby authorize any information requested below as well as any radiographs taken within last three years to be forwarded to the above address or emailed to info@officeforms.ca
Date of last Bitewings: ____________________

Date of last PAN / FMX: ____________________

Date of last complete exam : ____________________

Date of last recall exam : ____________________
Doctor's Address:
Doctor's Phone Number:
Phone Number
Doctor's Email :
example@example.com
Patient Name: *

First Name Last Name
Patient's Date of Birth:

Month Day Year
Patient Signature: *

Clear
Date:

Month Day Year
Date
Email (If you want to receive the copy of submitted form.)
Should be Empty: