Authorization for Release of Dental Records to Dalseth Dental

Download and print the Authorization of Release of Dental Records (PDF) or complete the appropriate release form below.

Authorization for Release of Dental Records to Dalseth Dental

Date
MM slash DD slash YYYY
Patient Information
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Email
Dental Clinic
Dental Clinic
Address
Street Address Address Line 2 City State ZIP Code
Phone
Authorization
I authorize the release of my dental and medical information to Dalseth Family and Cosmetic Dentistry (bitewings within 18 months, panoramic and/or full mouth series within 5 years).
Signature