I hereby authorize my Physician to release any pertinent facts regarding my child's medical history to Dr. Brian Hatch of Mountain View Pediatric Dentistry.

Sincerely,

Dr. Brian Hatch, DMD

Board Certified Pediatric Dentist

Mountain View Pediatric Dentistry

1904 Wellspring Avenue SE, Ste. 105

Rio Rancho, NM 87124

505-415-0462

Officemanager@mvpedsdental.com