Authorization to Release Records and X-rays
Each adult patient must sign his/her own Authorization to Release form
Requesting records from:
Doctor: ______________________________________
Address: ______________________________________
______________________________________
______________________________________
Authorized to release records and x-rays to:
Doctor: Randy Otterholt, D.D.S.
Address: 6817 N. Cedar Rd, Ste 102
Spokane, WA 99208-4277
(509) 327-4469
Patient Information:
Your name: ______________________________________
Address: ______________________________________
______________________________________
______________________________________
______________________________________
Patient Signature
_______________________
Date
