Date of Birth:

Information to be released:

Copy of complete dental chart
Copy of dental x-rays
Other (describe):

Dates Covered:

All treatment rendered in this office or by this dentist
Limited to treatment dates for conditions described above

Purpose of Release:

Transfer of records
Second Opinion
Other:

Expiration Conditions:
This consent will expire on (date): or 180 days from today unless revoked earlier in writing.

Other Conditions:

Patient Name (print):

Person Authorized to Sign for Patient (if applicable):

Signature:

Date:

Submit