Brian Hatch, DMD
Board Certified Pediatric Dentist
Mountain View Pediatric Dentistry
1904 Wellspring Avenue SE, Ste. 105
Rio Rancho, NM 87124

Record Release Authorization

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.

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.