• Pediatric Dentistry




  • Date Format: MM slash DD slash YYYY
  • Please enter a number from 0 to 50.
  • Required to send the filled forms to you.
  • I am requesting The Little Teeth Workshop to release all the dental/medical records and x-rays of my child be sent to the email/fax number below.

    Understanding this Authorization

    This allows the release or obtaining of information that exists in the patient’s dental/medical record when the form is signed, as well as information created after the form is signed until it expires.

    I may withdraw my permission at any time by providing written notice to the above-named provider releasing the information.

     If I withdraw my permission, any information that was already released cannot be retrieved.

    Information released by The Little Teeth Workshop may be released again by the person or organization that receives it and is no longer protected under federal privacy laws. The Little Teeth Workshop will protect information it obtains as required by federal privacy laws.

    I understand my permission is voluntary and I/my child will receive treatment whether or not I sign this form.

    By signing, I understand that I am authorizing The Little Teeth Workshop to release/obtain information as described above.