Mountain Park Dentistry Dr. Mow D.D.S.
PATIENT CONSENT FOR RELEASE OF MEDICAL INFORMATION
Due to the HIPPA laws that are now in effect we must have your written authorization to release your medical information to a person other than yourself. Understand that your information may need to be discussed with your current physician and/or referred to/or/ from specialists in regards to scheduling of procedures, consultations and health history that may impact your dental health. Only the information needed to do this will be released.

Please inform us of any changes you need to make in the future.
Who may we release your dental information to?
- Spouse
- Parent
- Son/Daughter
- Guardian
- Other
List Names
Print Pt Name
Patient Signature
Date
MM slash DD slash YYYY

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Patient Consent of Medical Information Form

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