Authorization for Records Release Form

MM slash DD slash YYYY
MM slash DD slash YYYY
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:
Address
To be sent via
For internal use only:
MM slash DD slash YYYY
The owner of this website has made a commitment to accessibility and inclusion, please report any problems that you encounter using the contact form on this website. This site uses the WP ADA Compliance Check plugin to enhance accessibility.