Informed Consent for Records Release Please complete this Consent for Records Releaset form below. If you have any questions call us on (615) 915-6090. Please send dental and health history records as well as ISP and Risk Tool information for:Patient name:(* required) First Last Patient date of birth:(* required)MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 To: Dr. Michael D. Vaughan, DDS and Associates330 Wallace Road, Suite #106Nashville, TN 37211 615-915-6091 (fax) or e-mail: maria@mdvdds.com SubmitName of Legal Guardian or Authorized Representative:(* required) If not applicable use 'self'Today's date:(* required) MM slash DD slash YYYY Do you wish to receive a copy of this Consent?(* required) Yes No E-mail address:(* required) Please sign(* required) Reset signature Signature locked. Reset to sign again Important: You consent to sign this document electronically.
