Dr. Gregory Sweeney D.D.S
(315) 458-3775 (315) 458-2845 Fax
I,__________________________do hereby consent and authorize,__________________________to disclose to Dr. Sweeney information in my records, including current and previous dental records from other practitioners, hospitals and or clinics which are part of my records.
Date of Birth,__________________________________Last Prophylaxis,
* FMX * PA's * BW's
* PANO * Perio Charting
Dentist Name,____________________________
Address,____________________________________
Phone Number,___________________________________
Patient or Guardian signature,____________________________Date,____________________________
Print name,____________________________________