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Authorization to Release Dental Records
Patient (or Parent or Legal Guardian) First & Last Name
Date Of Birth
Address
City
State
Zip Code
Phone
Are you requesting release for any dependents?
Dependent Name
Date Of Birth
Dependent Name
Date Of Birth
Dependent Name
Date Of Birth
Dependent Name
Date Of Birth
Dependent Name
Date Of Birth
I hereby authorize the release of protected dental information of the above-named patient from the following person or facility to Carrie B. Reddish DMD, PC at office@reddish.dentist (no.com):
Name of the Dentist or Dental Facility:
Dental Facility Email
Dental Facility Address
Dental Facility Phone
Please email the most recent
BWS &
PAN/FMX
to
office@reddish.dentist
(no.com)
Patient/Legal Guardian Signature
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Signature Pad
Date
Carrie B. Reddish D.M.D., P.C.
1233 Highland Avenue Needham, MA 02492 TEL. (781)444-2282
office@reddish.dentist
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