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FERPA Release Form

Dental Assistant Services
1306 Highway 33, Suite 3A
Farmingdale, NJ 07727
732-919-1816

In order for Dental Assistant Services to release any information about you to another party you must complete the form below providing your consent.  After you complete this form in its entirety and print it out, it may be hand delivered, mailed, or faxed in.  We cannot accept this form transmitted electronically through this website, because we need to have your signature.  Please click here for our contact information or click here to learn more about FERPA.

Release InformationI hereby grant Dental Assistant Services permission to share the following information about me and/or my educational records past and present:

  Attendance Records
  Courses taken and/or taking
  Grades

  Financial Information (payment history, money owed, etc.)
  Educational Progress (how well you're doing)

  Your location (e.g., if you are or were in class today)   Any and all information

  Other:

This information and only the information indicated above may be shared with the following party:



I understand that the name indicated above may be either an individual or the name of a practice, office, agency etc., in which case my information may be shared with anyone who identifies themself as working with or for that group.  If I wish to release my information to more than one individual and/or group I understand that I must fill out a separate release form.

This release form shall be effective from the date I sign below in perpetuity, unless I have indicated a specific future date here:

This form shall be valid until       

I attest that I will be, am currently, or was previously a student at Dental Assistant Services, that I am of legal age (18 or older), and that I understand that I am granting permission of my own free will for the release of my records as indicated above. 

Date of birth:            Last four digits of Social Security Number:

Signature: ___________________________________________
Today's Date: _______________