New X-Ray Release Form

Patient Information

Release Information

I hereby authorize the release of my dental records:

From: Dental Office

TO: Dolphin Dentistry
Address: 318 McLeod Street, Ottawa, ON, K2P1A3
Phone Number: 613-234-5758

Type of Records to Be Released

Please check all that apply:

Authorization & Signature

I understand that:

• This authorization is voluntary and may be revoked at any time in writing.
• Revocation does not affect records already released prior to the revocation.
• Information disclosed may be subject to re-disclosure and may no longer be protected by HIPAA.
• A fee may be charged for copying and mailing records.