Release Of Records

Silva Family Dentistry, LLC

Shawn Silva, D.M.D 42 lehner Street, P.O Box 2119 Wolfeboro, NH 03894

Tel: 603-569-9250
Fax: 603-569-9298
Email: sfd@atlanticbn.net

Date

I hereby authorize Silva Family Dentistry to send or receive information from my dental care records to:

Dr.

Address

City

State

Zip

Patient' s Name

Date of Birth

Address

City

State

Zip

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.

Patient Signature

(Parent or Legal Guardian if patient is a minor)

Your information will be encrypted.