PATIENT MEDICAL INFORMATION RELEASE FORM TO NEWTONBROOK DENTAL

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Patient:
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To transfer information to:

Newtonbrook Dental
Dr. Mark Safari & Associates

139 Finch Avenue West
North York, ON M2N2J1
Phone: 416 223- 2453
Fax: 416 223-6042
Email: Info@newtonbrookdentistry.com

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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