Smith + Heymann Release of Records Form

Release of Records
I hereby request and give my permission to Smith & Heymann Orthodontics to provide:

Name

Street Address

CityState / Province

Postal / Zip Code
Email
example@example.com
Any and all information he /she may request with respect to the orthodontic care of:

First NameLast Name
Such records may include medical care and treatment, illness or injury, dental history, medical history, consultation, prescriptions, x-rays, models and copies of all dental records and medical records.

I agree to pay the cost of duplicating any records. A photograph of this release will be as effective and valid as the original.
(Patient, Parent, Legal Guardian or Custodian of the Patient)

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient/Guardian Email
example@example.com
Cell #
Please enter a valid phone number.Format: (000) 000-0000.
Patient, Parent, Legal Guardian or Custodian of the Patient Signature
Should be Empty: