Release of Dental Records to Forestwood Dental

PATIENT INFORMATION:
Name:
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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

INFORMATION TO BE DISCLOSED:
All Radiology films/images taken in the past 5
years to be emailed to the above address
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Max. file size: 64 MB.
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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