Box 39

Patient signature block: The patient is defined as an individual who has established a professional relationship with a dentist for the delivery of dental health care. For matters relating to communication of information and consent, this term includes the patient's parent, caretaker, guardian, or other individual as appropriate under state law and the circumstances of the case.

This information comes from the Patient Information screen, Information tab, Release of Information check box. The Date is the current system date.