Patient Information Release

I authorize Dr. Antalis permission to give copies of any dental/medical records via mail or e-mail to my other health care providers including medical doctors, chiropractor, physiotherapists, E.N.T. specialists, neurologists, etc. or lawyers acting on my behalf.

I release you from all legal responsibility or liability that may arise from this authorization. *

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Patient Name: *

By submitting this form I accept all of the above conditions.



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1500 Deerpath Drive
Cambridge, OH 43725

(740) 630-9797

Opening Hours

Monday & Tuesday: 8am–4pm
Wednesday: 11am–7pm
Thursday: 8am–4pm
Friday: 7am–3pm

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