Patient Authorization To Release Confidential Information

Norwalk Dental Care

5 Eversley Avenue

Norwalk, CT, 06850

to disclose and provide copies of all clinical treatment records and information concerning my care, which is in the possession of this person or entity, to:

These records include, but are not limited to: personal patient Information, medical and dental histories, examination records, radiographs, clinical photographs, treatment plans, treatment records, referral and consultation recommendations and reports, diagnostic models, and other related materials.

I expressly release from liability the above-named person or entity from all liability arising from compliance with this request and disclosure of the requested information.

Signature of:

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.