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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
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
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