Dental Records Release Form

"*" indicates required fields

Date

Your Phone Number

Your First Name*

Your Last Name*

Patient Name*

Patient Date of Birth*

Your Relationship to Patient (Mother, Father, Legal Guardian, etc.)*

Photo Identification

Max. file size: 1 MB.

All release forms must have a copy of the parent/guardians’ photo ID attached or records will not be released. Please ensure that picture of identification documents are clear and easy to read.

Please choose the location of your most recent visit*

Please Release Patient Dental Records to:*

Name (first/last or name of Dental Practice)

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Fax Number

Reason For Records Request*

(i.e. moving out of the area, changing practices, etc.)

Records Needed By*

Please allow two business days for the records to be available.

Additional Notes/Special Requests

Unless otherwise requested, we will provide radiographs only.

Signature

*By signing this form, I verify that I am the legal representative for the patient listed above and authorize the release of dental records.

Dental Records Release Form

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