General, Cosmetic, and TMJ Dentists Serving Arlington, South Riding, and Nearby Areas of Northern Virginia AUTHORIZATION TO RELEASE CONFIDENTIAL PATIENT INFORMATION Location?*ArlingtonSouth RidingEmail Address* Patient or parent/guardian name:* I hereby request and authorize: Name of practice:* Dentist name:* Address:* 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 [email protected] P: 703.327.7705 F: 703.327.0742 Arlington Dental Aesthetics 4141 N. Henderson Rd. Ste. 16 Arlington, VA 22203 [email protected] 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. Patients included in this release (name & date of birth):* Signature* Date* MM slash DD slash YYYY Δ
