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