Medical / Dental Information Release

Kevin M. Knierim DMD

1000 Regency Ct. Suite 101 Toledo, OH 43623

Name

Date of Birth

RELEASE OF INFORMATION

I authorize the release of information including the diagnosis, treatment, dental records, x-rays, and examinations rendered to me and claims information. This information may be released to:

Spouse

Children

Parent

Other

Please list the names of the people you authorize to receive this information in the box below

This information is not to be released to anyone other than my insurance company for payment reason.

This Release of information will remain in effect until terminated by me in writing.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

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