Release of Dental Records Release of Dental Records to Newtonbrook Dental Newtonbrook 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 Newtonbrook Dental.Patient Name: First Last Please send any requested information and/ ot records to: Newtonbrook Dental Dr. Mark Safari & Associates 139 Finch Avenue West North York, ON M2N2J1 Phone: 416 223- 2453 Fax: 416 223-6042 Email: Info@newtonbrookdentistry.com Verified Signature of the patient listed above / or legal representative :(Required)Date: MM slash DD slash YYYY
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