Release of Records Date - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Dental Provider / Clinic Name: (where records will be coming from) * Required Dental Provider/Clinic Name Address * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Dental Provider/Clinic Phone * RequiredDental Provider/Clinic Email Consent * Required I authorize the release of dental records and x-rays relevant to dental treatment.I authorize the release of dental records and x-rays relevant to dental treatment, and request that they be transferred to: Dental Health Services, Minnewaska PLLC | Glenwood, MN 56334 Email: [email protected] | Fax: (320) 634-3567 | Phone (320)634-3556Consent * Required I agree my signature on this document is as valid as if I signed the document in writing.This is to be used in conjunction with the use of electronic signatures on all forms regarding any and all future documentation with a signature requirement, should I elect to have signed electronically. Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions. Patient First and Last Name * Required First Last Patient Birthdate - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Consent * Required I agree and understand that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.
