RELEASE OF MEDICAL INFORMATION

Date:

Re: (last name, first name)

Date of Birth:

I, the undersigned, authorize the Myofunctional Clinic of Bellevue, PLLC to release any necessary medical information during my treatment to the following professionals listed below (please include contact information next to name):

Physician:

Dentist:

Orthodontist:

Allergist:

ENT Physician:

Insurance Name:

Other:

Patient/Legal Guardian/Parent Signature:

Date:

Your information will be encrypted.