Release of Dental Records Release of Dental Records to Forestwood Dental Forestwood Dental is requesting patient information from the following office: Consent I, the patient,(Name listed below), authorize the release of my dental records and x-rays to be sent to the office of Forestwood Dental.Patient Name: First Last Please send any requested information and/ or records to: Forestwood Dental Dr. Mark Safari & Associates 11390 Major Mackenzie Dr E A1 Richmond Hill, ON L4S 0A1 Phone: (647) 360-1363 Fax: (905) 770-0671 Email: Info@newtonbrookdentistry.com Verified Signature of the patient listed above / or legal representative:(Required)Date: MM slash DD slash YYYY
Forestwood Dentistry, Richmond Hill DentistsForestwood Dentistry, Richmond Hill Dentists