Release of Records

Release of Records
I authorize Encino Tooth Fairy, office of Dr. Lecia Harmer, Dr. Julia Endrizzi & Dr. Elite Mekel to receive a copy of my child's/children's complete dental records, including ALL existing x-rays and any pending treatment needed, to be sent to: tinydds@gmail.com
Child #1 Name and Date of Birth
Child #2 Name and Date of Birth
Child #3 Name and Date of Birth
Child's Previous Dentist/Office*
Parent/Legal Guardian Name
Signature

Clear
Date Reservation
Date

MonthDayYear
Date
Should be Empty: