Information Release Form
To obtain your former dentist's dental records, we need your authorization.
DR. JEFFERY LEE EDWARDS
431 Boler Road. Unit 8. London, Ontario. N6K 2K8
Telephone: (519) 471-5110. Fax Number: (519) 471-8127
office@byronwooddental.com
Name of your former dentist:
Phone # of your former dentist:
Fax # of your former dentist:
Email address of your former dentist:
Print name of patient #1, please:
Date of patient's birthday:
Print name of patient #2, please:
Date of patient's birthday:
Print name of patient #3, please:
Date of patient's birthday:
Print name of patient #4, please:
Date of patient's birthday:
Print name of patient #5, please:
Date of patient's birthday:
I authorize you to release the following information and records to Dr. Jeff Edwards:
Your former dentist needs to fill out the following questions:
Recent radiographs (bitewings - last 2 years, panoramic last 7 years):
Date of last recall exam:
Date of last initial exam (01101, 01102, 01103)
Any other pertinent information:
AUTHORIZATION FOR RELEASING INFORMATION
I release you from all legal responsibility or liability that may arise from this authorization.
Signature of Patient, Parent or Legal Guardian
Date when you sign this form:
Signature of Patient, Parent or Legal Guardian
Date when you sign this form:
DR. JEFFERY LEE EDWARDS
431 Boler Road. Unit 8. London, Ontario. N6K 2K8
Telephone: (519) 471-5110. Fax Number: (519) 471-8127
office@byronwooddental.com
