Dental Records Release Form

    Date:
    To Dental Office/Dr.:
    Patient's First Name:
    Patient's Last Name:
    Patient's Date of Birth:
    To whom this may concern,

    We at Richmond West Dental and the below patient, would like to thank you and your staff for the care you have provided.

    For us to maintain continued and quality care for the patient, we kindly ask if you could forward the most recent radiographs and dental records to our office at your earliest convenience.

    The signature below represents the patient's authorization and release of their records along with any legal responsibility or liability that may arise from this authorization.
    Patient's Signature:

    Regards,
    Richmond West Dental Team

    500 Richmond St W
    Suite 128
    Toronto, ON. M5V 3N4

    P: 416 366 0777
    F: 416 366 1117

    www.richmondwestdental.com

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