Swanson Dental Associates - Release form

Authorization for Release of Dental Records and X-rays

Patient or Guardian Patient or Guardian First Last
Email
Phone Phone - ### - ### ####
Patient or Guardian hereby authorizes the release of records concerning Patient(s) dental health and copies of all x-rays and all treatment notes to:

Swanson Dental Associates
1135 116th Ave NE Suite 580
Bellevue, WA 98004
Patient 1 Patient 1 First Last
Patient 2 Patient 2 First Last
Patient 3 Patient 3 First Last
PREVIOUS DENTAL PROVIDER
Dr. Name
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Fax Fax - ### - ### ####
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Full Name

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