3103 Big Trail Drive, Jackson, WY

307-733-4778

Monday - Friday

Release of Records

Release of Records

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Information to Be Released From:

I hereby authorize the release of the above information contained in my dental records which may contain personal and confidential information. I release you from any legal responsibility or liability that may result from this authorization. Authorization is valid for 90 days and may be revoked in writing any time prior to 90 day by notifying the releasing party.
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P.O. Box 4935 Jackson, Wyoming 83001, (307) 733-4778, (307) 734-8041 (fax), teeth@larsenfamilydentistry.com