Authorization for Records Release Form

Date of Request

Patient Name

Patient Date of Birth

FROM: Oscar Hernandez Jr, DMD, Oscar J. Hernandez, DMD & Thao Nguyen, DMD

I hereby authorize the release/request (circle one) of copies of my dental records and radiographs and request that they are transferred to:

Name of Patient/Dentist

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone Number

Email Address

To be sent via

Mail

E-mail

Signature of Patient/Guardian

For internal use only:

Date received

Staff Signature