Authorization to Release Dental Information Patient's Name* First Last Today's date* Date Format: MM slash DD slash YYYY Practice to release records:Email to Send / Request RecordsFill out the email address of the practice releasing/requesting information. Practice Releasing/Requesting Phone NumberAuthorization I authorize you, South Waterfront Dental, to release my records to the above practice. I authorize the above dental practice to release my records. Please forward any radiographs and chart notes to: South Waterfront Dental Todd L. Beck, DMD 3671 SW River Parkway Portland, OR 97239 [email protected] 503-841-5658 Patient's signature*By typing your full name here, you are electronically signing this document. First Last NameThis field is for validation purposes and should be left unchanged.