I, hereby give my consent to , to release to:
Dental Health Professionals 7800 US 131 S. Cadillac, MI 49601 Phone: 231-775-9797 Email: info@dhpcadillac.com
Information from and copies of the dental/health care records of:
Patient Name(s)
Birth Date(s)
I authorize to release the above-named patient(s)’s entire dental/health care records, including information related to HIV infection or AIDS, any communicable disease or infectious disease, records and any other dental or health care records in any format. This authorization shall be effective following the date of signature. However, I understand that this authorization may be revoked at any time by giving written notice to Dental Health Professionals. A photocopy or fax of this authorization shall constitute a valid authorization.
Signature (Patient or Representative)
Date
Relationship to Patient (if applicable)
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