Make an Appointment with Chanhassen Family Dentistry
Chanhassen Family Dentistry
Voluntary Release of Information Form

  • 8116 Mallory Court
    Chanhassen, MN 55317

  • Voluntary Release of Information

  • Date Format: MM slash DD slash YYYY
  • At Chanhassen Family Dentistry, P.A., we are dedicated to protecting your right to privacy. That is why if you would like to authorize someone, such as a spouse, relative, or friend to help you with matters concerning your dental/medicalrecords, we ask you to review, complete and sign below.

    Note that the completion of this authorization is completely voluntary. This will allow us to release information about your dental health to the person(s) specified.Please remember,this concerns your personal records and the form can only be signed by you or by your legally authorized representative (such as a power of attorney, guardian or conservator).

  • Date Format: MM slash DD slash YYYY
  • (If signed by someone other than the patient)