Brian Hatch, DMD Board Certified Pediatric Dentist Mountain View Pediatric Dentistry 1904 Wellspring Avenue SE, Ste. 105 Rio Rancho, NM 87124 505-415-0462 Order Number Record Release Authorization Patient's Name * Patient's Date of Birth * I hereby authorize and request the following provider to disclose my child’s dental records and give copies to Mountain View Pediatric Dentistry: Please release any and all records and information which you may have in your possession, including but not limited to the following; dental records including operative records, diagnosis, dental history, findings and procedures, treatment notes, radiographs, diagnostic models and additional materials. I hereby authorize and request Mountain View Pediatric Dentistry to disclose my child’s dental records and give copies to: Parent Signature * In consideration of such disclosure on the part of the above named parties, I hereby release them from any and all liability arising from such disclosure. Today's Date * Reason For Request/Release *
