Patient Forms

Medical Information Release Form

Complete the form below before your visit. If you have questions, please call Fujioka Family Dentistry at 360-696-4439.

required field — please fill out all required fields.

This form may contain sensitive personal or health information. Submission details are not included in notification emails.

AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION TO:

Fujioka Family Dentistry
215 NW 78th St
Vancouver, WA 98665
360-696-4439

Patient Name:

First

Date of birth:

Previous Name:

First

Name (of health care provider):

Address

Street AddressAddress Line 2CityState / ProvinceZIP / Postal Code

Phone #:Fax #:

The request and authorization applies to health care information relating to the following treatment, condition or dates of treatment (check all that apply):

If other please specify:

Acknowledgement:

I understand that my express consent is required to release any health care information relating to testing, diagnosis, and/or treatment for HIV/AIDS, sexually transmitted diseases, psychiatric disorders/mental health, or drug and/or alcohol use.

Signature:

Signature of patient or patient's authorized representative.

DateRelationship:

Relationship or status if signed by anyone other than patient (parent or legal guardian).

Please click Submit only once. Processing may take a moment.