ROBISON DENTAL, PC – PATIENT RECORD RELEASE FORM

Robison Associates, P.C.
3235 Templeton Gap Road
Colorado Springs, CO  80907
719-630-7727
www. Robisondental.com

I request and authorize that the above-named doctor or health care provider to release the information specified below to Dr. Letha Robison. I understand that the information to be released includes information regarding the following condition (s):

AUTHORIZATION:  I certify that this request has been made voluntarily and that the information given is accurate to the best of my knowledge.  I understand that I may revoke this Authorization at any time, except to the extent that action has already been taken to comply with it.  Without my express revocation, this consent will automatically expire upon satisfaction of the need for disclosure, but in any event;