• 703-214-3183
  • Arlington, VA
  • 703-214-3183
  • Arlington, VA

Record Release Form

General, Cosmetic, and TMJ Dentists Serving Arlington, South Riding, and Nearby Areas of Northern Virginia

AUTHORIZATION TO RELEASE CONFIDENTIAL PATIENT INFORMATION

  • I hereby request and authorize:
  • to disclose and provide copies of any and all clinical treatment records and information concerning the below listed patients’ care, which is in the possession of this person or entity to:

    South Riding Smiles
    25055 Riding Plaza Ste. 250
    South Riding, VA 20152
    patient@southridingsmiles.com
    P: 703.327.7705
    F: 703.327.0742

    Arlington Dental Aesthetics
    4141 N. Henderson Rd. Ste. 16
    Arlington, VA 22203
    patient@arlingtondentalaesthetics.com
    P: 703.527.1020
    F: 703.527.4796
    These records include, but are not limited to: personal patient information, medical and dental histories, examination records, radiographs, clinical photographs, treatment plans, treatment records, refer real and consultation recommendations and reports, diagnostic models and other related materials. I expressly release from liability the above-named person or entity from any and all liability arising from compliance with this request and disclosure of the requested information.
  • MM slash DD slash YYYY

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