• AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION TO:

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

  • Date Format: MM slash DD slash YYYY
  • 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 of patient or patient's authorized representative.
  • Date Format: MM slash DD slash YYYY
  • Relationship or status if signed by anyone other than patient (parent or legal guardian).