Release of Records Consent
Fax: 360-841-7070 EMAIL: firstname.lastname@example.org
Date of Birth
Additional Family Members
Name of previous dental office
By checking this box and signing below, I authorize Dr. Brad Halleck's office to obtain my most current radiographs, periodontal chart, and necessary records from my previous dental office listed above.
Yes, I authorize my records to be transferred to TOWN DENTAL, the office of Brad Halleck, DDS via email to: email@example.com
Enter the message as it's shown
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm