I authorize my previous provider to disclose the following private information to the dental office, listed below, for records and diagnostic purposes:
Release to:
Canyon Park Dental • (425)485-6540
22833 Bothell-Everett HWY, Ste 205
Bothell, WA 98021
canyonparkdental@yahoo.com
Person authorized to make the request for records:
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.
Your information will be encrypted.