Online Patient Form

Request for Release of Information
Print blank form to fill by hand

*Patient Name :

Last name

First name

Mid name

Birthday :

*Address:

				City
Province		Postal		APT#


*	I hereby authorize Living Wellness Dental to obtain the information or records from
	for the following patients:

Information being requested:

Bitewings

PA’s

Panorex

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.)