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Records Release from Wendel Family Dental Centre

If you would like Wendel Family Dental Centre to duplicate and release your records, please fill-out our Record Release from Wendel Family Dental Centre form 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

(There is a minimum $30 charge to duplicate records not sent directly to another dental office.)

Patient's Name:*

Patient's Date of Birth:*

Patient's Phone:*

Patient's Email:*

Reason for Records Request:

We appreciate all comments and/or suggestions for improvement that you may have for us.

I request and authorize Wendel Family Dental Centre to release healthcare information of the patient named above to:

Office Name:*

Office Email:*

Office Phone:*

Office Address:

Street Address City State ZIP Code

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

Current X-rays

Treatment Record including Periodontal Charting (if available)

Other:

If Other Please List Here:

I understand that my express consent is required to release any healthcare information.

I am aware that there is some level of risk that 3rd 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)

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

One Great Smile Has Thirty-Two Parts

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Records Release from Wendel Family Dental Centre

Authorization to Release Health Care Information

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Wendel Family Dental Centre