Release Of Information

Date of Referral

Patient Name

Date of Birth

I, the undersigned, authorize Magar Myofunctional and Speech Servies, PLLC to release any necessary medical information during treatment of the above listed patient to the following professionals listed below (please include contact information next to name):

Physician

Dentist

Orthodontist

Alergist

ENT Physician

Insurance Name

Other

Signature

Date

If Child, Parent/Legal Guardian Signature

Date

Your information will be encrypted.