Release of Records

Name

Date of Birth

This is to authorize the release of my records. Please forward a copy of my records to:

Dr. John D. Miller D.D.S., P.A.

399 Tequesta Drive, Suite 104

Tequesta, FL - 33469

Office Phone: (561) 746-4004

Office Email: jmiller@inletdentistry.com

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, Parent, or Guardian Signature

Date

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