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Records Release

Dr. Gregory Sweeney D.D.S

(315) 458-3775 (315) 458-2845 Fax

I,__________________________do herby 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,____________________________________


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North Syracuse Office

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Monday:

8:00 AM-5:00 PM

Tuesday:

8:00 AM-5:00 PM

Wednesday:

8:00 AM-5:00 PM

Thursday:

8:00 AM-5:00 PM

Friday:

Closed

Saturday:

Closed

Sunday:

Closed