• Authorization for the Release of Dental Records

  •  -  -
    Pick a Date
  • I hereby authorize Dr.         to release the information contained in my dental records to Madjid Matin, DMD, LLC.

  • Email to:

    admin@chevychasedental.com

    I recognize that email is not a secure form of communication. There is some risk that any individually identifiable health information and other sensitive or confidential information that may be contained in such email may be misdirected, disclosed to, or intercepted by unauthorized third parties.

    Mail to:


    Madjid Matin, DMD 
    5530 Wisconsin Avenue, Suite #1110 

    Chevy Chase, MD 20815


    Any and all information may be released including, but not limited to x-rays, photos, intraoral pictures, and clinical notes.

  • This authorization is effective now and will remain in effect until    Pick a Date (date)  

  • Clear
  •  -  -
    Pick a Date
  • Should be Empty: