Dental Patient Request for Medical Release of information from a Health Care Provider PATIENT MEDICAL INFORMATION RELEASE CONSENT TO DR. MARK SAFARI, FORESTWOOD DENTAL Today's Date MM slash DD slash YYYY Patient Name: First Last Patient's Date of Birth: MM slash DD slash YYYY I authorize my health care provider(s) including any specialist(s), if applicable, to discuss and to release any pertinent medical information to my dental Provider at Forestwood Dental office for the purpose of disclosing any medical conditions or concerns that may affect my dental treatment. I also authorize my medical Doctor(s) or Medical institution to speak with my Dental office regarding the state of my general health or any medications I am currently on. I am aware that my personal past and or current medical history and/ or information will only be released for the purpose of providing clearance for any future dental procedures that I may need. Pursuant to the Personal Health Information Protection Act, 2004 (PHIPA), I understand the purpose for disclosing this personal health information and I am also fully aware that I can refuse to sign this consent form. Please send information to: Forestwood Dental Dr. Mark Safari & Associates 1390 Major Mackenzie Drive East A1 Richmond Hill, ON L4S0A1 Phone: 905 770 0099 Email: Info@forestwooddentistry.ca . Once fully read and reviewed, please make sure that the above document is filled out appropriately. By signing below and submitting this document, we are assuming that it has been read in its entirety. All patient signatures will be verified for authenticity in the office. Signature of patient / legal rep:Date MM slash DD slash YYYY
Forestwood Dentistry, Richmond Hill DentistsForestwood Dentistry, Richmond Hill Dentists