18540 SW Vincent St., Beaverton, Oregon 97078

Phone: (503) 649-5900

DENTAL AUTHORIZATION

Authorization to Release Dental Information

Patient's Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Previous Dentist Information
Previous Dentist Name:
Previous Dentist Phone:
Information Requested:
- Most recent X-Rays
- Most recent full mouth series
- Periodontal charting
Reason for Request:
- Change in dental provider
- For insurance or legal purposes
- For personal use or other
If For Personal Use or Other:
By signing this form, I am agreeing to the following: The above named is authorized to release my records as indicated. This release of information authorization is valid for six months and may be revoked at any time. I understand Slater Family Dental reserves the right to charge a fee for duplicating records.
*
- I have read these statements and I agree with them.
Signature
Date of Signature: 04/18/2024
Please email records to: [email protected]
Phone
This field is for validation purposes and should be left unchanged.

News

Dr. Slater gave me a smile, I couldn’t be more thrilled!

“Dr. Slater didn’t give me my smile back. I don’t think I ever had one.

Dental Implant Procedure: Everything You Need to Know

If you are one of the many individuals who are missing one or more teeth…

Back-To-School Hygiene

As we prepare for schools in Oregon to start back up, we’d like to remind…

Navigation

Location

18540 SW Vincent St., Beaverton, Oregon 97078

Phone: 503-649-5900
Fax: 503-649-0362
Text: 503-649-5900

Get Social!

Copyright © 2024 | All Rights Reserved | Slater Family Dental