Luck Dental Clinic, Inc.
308 First Street South
PO Box 550
Luck, Wisconsin 54853
Phone: (715) 472-2211• Fax: (715) 472-4485
Authorization for the release of dental information
Health Care Provider
You are hereby authorized to release to ___________________________ and its
representatives any and all information you may have concerning my dental condition,
including x-rays, which you have obtained as a result of history, examinations, testing,
diagnosis, treatment and prognosis.
This authorization shall remain valid for one year from today’s date. A signed copy of
this authorization and DO / DO NOT (circle one) request a copy, and if requested, do
acknowledge a receipt thereof.
I have read this authorization before signing it.
Print or type name
If not signed by the patient, please indicate relationship:
[ ] parent or guardian of minor patient
[ ] guardian or conservator of incompetent patient
[ ] beneficiary or personal representative of deceased patient