Records Release Form to Wendel Family Dental Centre

If you would like a previous provider to release your records to Wendel Family Dental Centre, please fill-out our Records Release to Wendel Family Dental Centre for below. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.

"*" indicates required fields

Authorization to Release Health Care Information to WFDC

Patient's Name:*

Patient's Date of Birth:*

Patient's Phone:*

Patient's Email:*

I request and authorize:

Name:*

Email:*

Phone:*

Address:

Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

To release health care information of the patient named above to:

This request and authorization apply to (please check one of the following):*

Current X-rays

Other:

If Other Please List Here:

I understand that my express consent is required to release any healthcare information relating to testing, diagnosis, and treatment.

I am aware that there is some level of risk that third parties might be able to read unencrypted emails.

X - Signature of patient, parent or court appointed legal guardian.*

Date*

MM slash DD slash YYYY

Please also type your signed name here:*

Signed Name

Relationship or status if signed by anyone other than patient (i.e., parent, court appointed legal guardian)

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.