Release Form

Date*

Patient Name(s)*

Please Accept This Signed Request as My Authorization to Release and Transfer the above Mentioned Records to Dr. Malak of Peace Park Dental.

Date

Type Your Name, This Constitutes a Legal Binding Release.

Previous Dental Office

Phone

Fax

This Section to Be Completed by the Previous Dental Office and Would Be Greatly Appreciated – Please Return Asap.

Date of Most Current Complete Oral Examination

Date of Most Current Scaling Appointment

Date of Most Current Panorex

Date of Most Current Complete Recall Examination

Date of Most Current Bw's

Any Additional Pertinent Information

This Patient is scheduled for an appointment at Peace Park Dental on

Peace Park Dental Employee

This Form has been

Emailed

Mailed

Faxed

On Date

Untitled

This field should be left blank

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