REQUEST OF RELEASE OF HEALTH INFORMATION

Patient’s First Name:

Patient’s Last Name:

Hereby grants permission to:

Print Name of Doctor:

Doctor’ Address:

Doctor’s Email:

To release information related to my Dental/Health history, status, treatment and copies of my Dental/Health records, X-Rays and any test results to:

Dr. Anett John, DDS, LLC
5530 Wisconsin Avenue, Suite 1240
Chevy Chase, MD 20815
301-652-3317
drajohndds@gmail.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 Signature:

(If a minor, a parent or guardian must sign)

Date:

Your information will be encrypted.