Dental Authorization Form

Authorization to Release Dental Information

  • Date Format: MM slash DD slash YYYY
  • Previous Dentist Information

  • 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.
  • Date of Signature: 06/19/2019
    Please email records to: [email protected]
  • This field is for validation purposes and should be left unchanged.



3895 SW 185th Ave Ste 130
Aloha, Oregon 97078

Phone: 503-649-5900
Fax: 503-649-9047
Texts: 503-649-9824

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