Consent for Information Release
________________________                                                         ______________
   Patient's Name                                                                                 Date of Birth
 
                                                                                                          _______________
                                                                                                               Today's Date
I hereby Authorize:
 
____________________________________
           Current office or Doctor's  Name
 
To release the following confidential information regarding the patient's care, treatment and services:
____Complete Dental Chart (including all progress notes, treatment notes and treatment plans)
 
_____Xrays /Photos
 
_____Other (eg. Insurance Information etc. )
 
Purpose of Release:

____Referral         _____ Continuation of care           ____Second opinion         ____other
 
     My Records are to be released to:
                                              
                                           Southern Ohio Periodontics
                                                      Dr Rupa Hamal DMD, MS, MPH
                                                             147 Pinckney Street
                                                              Circleville OH 43113
                                                                 Tel: 740-474-8558
                                                             ohperio@hotmail.com
 
Authorization: I certify that this request has been made voluntarily and that the information given above is accurate to the best of my knowledge.  I understand that I may revoke this authorization at any time , except to the extent that action has already been taken to comply with it.  I understand this consent will expire if records have been successfully released.
 
______________________________________                                         ____________
Signature of Person Authorized to Consent                                                       Date