Skip to content
Home
About Us
Biography
Office Manager
Services
Release Dental Records
Blogs
Dentist
Tips
Contact Us
Home
About Us
Biography
Office Manager
Services
Release Dental Records
Blogs
Dentist
Tips
Contact Us
Request An Appointment
Smiles For Kids – Authorization to Release Dental Records
Patient Information
Name
Email
Parent/Guardian Name
Phone Number
Email Address
I hereby authorize Smiles For Kids to:
Release my child’s dental records to:
Release my child’s dental records to:
Name of Provider/Practice
Address
Phone
Purpose of Release:
Purpose of Release
Transferring to a new dentist
Second opinion
Personal records
Other
Please specify your reason
Authorization & Signature:
I understand that this authorization is voluntary and that I may revoke it at any time in writing. I also understand that records may not be released without my written consent unless otherwise permitted by law.
Clear
Date
Send Message
REQUEST AN APPOINTMENT
Name
Phone
Email
Doctor
Dr. Danielle Lockwood
Date
Time
Message
Send
