FormsRelease of Records Notice of Privacy Practices Acknowledgement of Privacy Practices Authorization to Share Information Form New Patient Survey New Patient Information Patient Health History – Adult Patient Health History – Child Testimonial Release Form View the Notice of Privacy Practices HereRelease of RecordsI authorize the office of (insert in box below) to release copies of records including, but not limited to: X-rays (PAN, bitewings, full-mouth, etc.), copies of chart (patient history), and other related information. I also authorize the above named office to send digital copies of these records via their office email address to Dr. Giordano's office email: email@example.com.*If by mail, send to: Dr. Loius M. Giordano 864 Hooper Road Endwell, NY 13760 607-748-4151 (phone) 607-484-0061 (fax)This record release is for:Requesting records from (Office):*Name:* First Last Date of Birth* Name: First Last Date of Birth Name: First Last Date of Birth Name: First Last Date of Birth Electronic Signature (E-Signature) AgreementBy selecting the "I Accept" button, you are signing this Release of Records electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Release of Records. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You also represent that you are authorized to sign this Release of Records for all persons listed on this form.*I AcceptElectronic Signature:Name* First Last Today's Date* CommentsThis field is for validation purposes and should be left unchanged.