Authorization to
Release Dental Information
Request a Form
Transferring offices? We are sorry to see you go.
Please fill out the following information to request an authorization form. The form should be filled out and returned to Cypress Cosmetic and General Dentistry. Once your signed form is received, please allow up to 5 business days for us to process your request.
Return form:
In person
Via fax (321) 319-2303
Via email: Send attachment through secure portal