Advancing Dental Care In Our Changing World

Consent Form

hereby authorize to disclose its patient medical records, including medical, dental and pharmaceutical health information, to Dr. Gursharandeep Singh or any of him agents, in respect of the following patient.

Please provide any Pertinent Information/dental requests that you many have:

I direct that this personal health information is to be used only the recipient or the purposes of a dental assessment and/or treatment. I hereby waive any and all claims against in connection with this disclosure of this personal information. I also authorize a complimentary dental screening to be completed by Dr. Gursharandeep Singh and any of him agents.

Contact numbers for future correspondence regarding dental treatment.