Aimee M. Fujioka, DMD, PS 215 NW 78th St Vancouver, WA 98665 Tel: 360.696.4439 Fax: 360.696.4455
I request and authorize the following health care provider to release health care information of the patient named above.
The request and authorization applies to health care information relating to the following treatment, condition or dates of treatment (check all that apply):*
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.