Authorization to Release Patient Records

I authorize my previous provider to disclose the following private information to the dental office, listed below, for records and diagnostic purposes:

Previous Office:

Name

Address

Phone #

Fax/E-mail

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.

Patient Name

Relationship

Signature

Date

Your information will be encrypted.