Authorization for Release of Dental Records

Use this form to authorize your previous dentist to send the patient’s dental records to Senior Mobile Dental Services. It takes just a few minutes, and a family member or POA can complete it on the patient’s behalf.

Prefer paper? Download the printable PDF

Patient Information

Patient full name *

Date of birth *

Facility name

Facility address

Who Is Completing This Form?

Is the patient their own POA (Power of Attorney)? *

Yes, I am the patientNo, I am the family member or POA

Family / POA Information

Family / POA full name

Address

Cell phone

Work phone

Your phone number *

Your email *

Release Records From: Previous Dentist Office

Dentist / office name *

Phone number

Office address

Transfer Records To: New Dentist Office

Dr. Farideh Ali-Mohammadi (DDS), Senior Mobile Dental Services
368 Sweetflag St., Nepean, Ontario K2J 5Y7
Phone: (613) 854-8007 | Email: info@seniordental.ca

This authorization specifically permits the release of the following dental records:

X-ray documents
Treatment history
Diagnostic records (including models, photographs, and charts)
Any other pertinent information related to the patient's dental care

Authorization & Signature

I understand that the information released under this authorization may be protected by the Dentistry Act, 1991, including but not limited to HIPAA, PHIPA and PIPEDA. This authorization shall remain valid unless revoked in writing by the patient or family/POA. I understand that I have the right to revoke this authorization at any time, except to the extent that action has already been taken in reliance on it.

Full name (as signature) *

Date *

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