AUTHORIZATION TO RELEASE DENTAL INFORMATION

Please complete all sections of this Dental Information Release form below. If any sections are left blank, this form will be invalid and it will not be possible for your dental information to be share as requested.

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I hereby authorize East Grove Dental to share the information listed in Section II of this document with the Person(s) or organization(s) I have specified in Section IV of this document. 

Section II - Dental Records Information

I would like to give East Grove Dental permission to:

Section IV

My consent to disclosure of records shall be effective until I revoke it in writing.

This acts in lieu of your signature: