Bellingham Bay Dental Dr. Grant McClendon DMD 1118 Finnegan Way, Suit 101, Bellingham, WA 98225 (360) 676-0760 / Fax (360) 734-7198 info@bellinghambaydental.com I,* First Last , hereby authorize Bellingham Bay Dental to release information in my dental records to: Doctor's name and/or business name: Email PhoneFaxAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Information to be release: Radiographs and any other information in my dental records that would be useful for future treatment. Bellingham Bay Dental is hereby released from all legal responsibility or liability for the release of the above mentioned disclosure of information. I understand that I have the right to withdraw this authorization at any time and that such revocation must be in writing. Further, I understand that this authorization, without prior revocation, will expire 90 days from the date of signature. Signature*Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
