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Gregory B. Sweeney, D.D.S. | Records Release in North Syracuse

Dr. Gregory B. Sweeney, DDS       

5260 West Taft Rd. 

North Syracuse, NY 13212

P: (315) 458-3775, Fax 458-2845

Use Office Code "H6VHZ1"

Make A Payment

 


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,____________________________________