Record Release Request

Patient Information

Full Name *

Date of Birth *

Phone Number *

Recipient Information (previous dental office)

Recipient's Name (Dentist/Facility) *

Phone Number *

Email Address

Records to be Released *Full Dental RecordDate of last New Patient ExamDate of last Recall ExamDate & Copy of last PanoramicDate of last cleaningDate & Copy of BW's taken within the last 2 years

Authorization: I hereby authorize the release of my dental records . I understand that this authorization is voluntary and that I may revoke it at any time in writing.

Signature *

Sign here

Date *