Release of Dental Records to Newtonbrook Dental

PATIENT INFORMATION:

Name:
MM slash DD slash YYYY

AUTHORIZES:

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

INFORMATION TO BE DISCLOSED:
All Radiology films/images taken in the past 5
years to be emailed to the above address
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
Max. file size: 20 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.
MM slash DD slash YYYY