CALL TODAY - 905.892.5888

Have Questions?

Let's help you choose the right service

A bit more information

Do you have any information we need to know?

Almost done!

Leave your contact details and we'll get back to you asap!

Go Back

Release Form

Download PDF

Request for Release of Patient Records

Please Accept This Signed Request as My Authorization to Release and Transfer the above Mentioned Records to Dr. Malak of Peace Park Dental.
This Section to Be Completed by the Previous Dental Office and Would Be Greatly Appreciated – Please Return Asap.

Sorry we are closed for the day do to weather conditions. Stay Safe!

Thank you for understanding!