Dr. Brendan Wong 361 King Ave East, Unit #1 Newcastle, ON L1B 1H4Tel: (289) 274-4899 info@newcastlesmilecentre.comAuthorization For Release Of Dental Records To: Dr(Required) City(Required) Fax Number(Required)Phone Number(Required) Address(Required) I hereby authorize you to transfer my / our dental records and associated radiographs to the office of Dr. Brendan Wong, and/or Dr. Vernon D’Souza. Patient Name(s)(Required) Signature(Required)Date MM slash DD slash YYYY
