Medical/dental Information Release

MEDICAL/DENTAL

INFORMATION RELEASE

I,__________________________________ , parent or legal guardian of _______________________________ give

(Guardian’s Name)

(Child’s Name)

Pediatric Dental Specialists permission to release/obtain information contained in his/her medical/dental chart to:

To /From:

___________________________________

(Office Name)

___________________________________

(Street Address)

___________________________________

(City, State, Zip)

This information may include copies of medical/dental x-rays or photographs contained in the chart.

_________________________________

__________________

______________________________

Signature of Parent or Legal Guardian

Date

Relationship to Child

Pediatric Dental Specialists

3320 Los Coyotes Diag. #200

Long Beach, Ca. 90808

(562) 377-1375

Fax: (562) 377-1343

U:/PDS/PDS-0014 MEDICAL-DENTAL RELEASE FORM

REV 4/09

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Parent category: Legal