Authorization to Release Dental Information Patient's Name* First Last Today's date* MM slash DD slash YYYY Practice Requesting Films From: Email of PracticeFill out the email address of the practice releasing/requesting information. Practice Phone Number* 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 3580 S River Pkwy, 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. Δ
