Ammar Idlibi, DMD
Board Certified Pediatric Dentist
Jaimie Vassiliou, DMD
Orthodontist
Alesia Burge, DMD
General Dentist
     

Authorization for Release of Dental Records and X-rays

I,(guardian name)  , parent or legal guardian
of (child's name)  hereby authorize the doctors and staff of Kids Dental Care to release records or knowledge concerning my child's dental health to:
Doctor or Practice name:
Street Address:
City: Zip Code:
Practice telephone number:
Please state your reason for transfer:
Patient's Name: Phone: Email:
Signature (Parent/Guardian):
Date:
Print Name: Relationship:
Please enter code above in the field below.