Form

Authorization for Release of Information

I authorize you to provide Oakwood Smiles, PC any and all information you may have regarding my dental history, physical and laboratory findings, radiographs, treatment plan, treatment prescribed and your conclusions. A copy of this authorization shall be valid as the original.

Patient's First Name

Patient's Last Name

Date Of Birth

Address

City

Zip Code

Doctor or Practice Name you are requesting records from:

Doctor or Practice Phone Number

Address

City

Zip Code

At the patient's request, this letter is to request that a summary of their dental records and radiographs regarding your previous care be forwarded to this office at your earliest convenience. **Please forward the records to Office@OakwoodSmiles.com if you prefer to forward the records via email**

Sincerely,

S.V. Gritsiv, DMD

Patient/Legal Guardian Signature

Date