Click on Calendar, type the year 'YYYY' and pick the month & date.
Request for Release of Information
Print blank form to fill by hand

  Last name

  First name

  Mid name
* I hereby authorize Living Wellness Dental to obtain the information or records from
for the following patients:
Study Models
Probing Charts
Full Chart
* This is to certify that I consent to the dental procedures agreed to be necessary or advisable for myself, or my child / legal dependent, including the use of local anesthetic or other drugs as indicated. I understand that there are no guarantees that the procedures agreed to be necessary will resolve all or any of the described symptoms. I will assume responsibility for fees associated with those procedures, and I consent to the collection, use and disclosure of my personal information as set out above.

*Signature :
Date :
(Your digital signature (full name) is as legally binding as a physical signature.)