Waukesha Family Dentistry - Patient Authorization to Release Confidential Information Form

Patient Authorization to Release Confidential Information

Patient Name(*)

Please provide the patient or guardian's full name.

I hereby request and authorize Drs. Shoemaker & Gilson to disclose and provide current copies of radiographs concerning my care, which are in possession of this person or entity:

Name of new dentist, specialist, or patient

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Contact Phone

Please enter valid phone number (xxx-xxx-xxxx)

Street Address

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City

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State

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ZIP

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Terms and Conditions

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

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms and Conditions and this website's Privacy Policy. You must agree to the Terms & Conditions to submit this form online.

Electronic Signature(*)

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