PATIENT MEDICAL INFORMATION RELEASE FORM TO FORESTWOOD DENTAL Date MM slash DD slash YYYY Patient: Full name Date of Birth: MM slash DD slash YYYY Authorizes: To transfer information to: Forestwood Dental Dr. Mark Safari & Associates 1390 Major Mackenzie Drive East A1 Richmond Hill, ON L4S0A1 Phone: 905 770 0099 Email: Info@forestwooddentistry.ca I also authorize my medical Doctor or Medical institution to speak with my Dental office regarding the state of my general health or any medications I am currently on. Please disclose the following information to our office: Once fully read and reviewed, please make sure that the above document is filled out appropriately. By signing below and submitting this document, we are assuming that it has been read in its entirety. All patient signatures will be verified for authenticity in the office. Signature of patient / legal rep:Date MM slash DD slash YYYY
