PATIENT MEDICAL INFORMATION RELEASE FORM TO FORESTWOOD DENTAL

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Patient:
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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.

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.

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