Health care release authorization
7500 Old Military Rd NW #201 Bremerton, Wa 98311
PH (360) 692-4705 / FX (360) 692-4846
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Email *
Patients Name: *
Date of Birth *
I request and authorize the release of necessary dental health history of the patient named above to / from:
Office/Dr.'s Name *
Phone Number of office: *
This request and authorization applies to: *
Print Name *
Relationship to patient if signed by representative:
By entering your initials on the line below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge. *
A copy of your responses will be emailed to the address you provided.
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This form was created inside of Meadowdale Dental Center.