Authorization form Free Sonicare with new patient (Disclaimer) One per household and must be over 21.Authorization AUTHORIZATION TO RELEASE INFORMATION hidden Patient Date of Birth:name1 Released To/From:name1name1name1I request and authorize the above named doctor or health care provider to release my information to the organization, agency or individual named on this request.PURPOSE(S) OR NEED FOR WHICH INFORMATION IS TO BE USED:Transfer of recordsSecond OpinionOther Patient/Guardian Signature OR Signature File(Required) name1 Date of Birth:
