Form

Release of Information

Patient First Name

Patient Last Name

Patient Email

Date Of Birth

Release of Information

Records may be released to the following person/ dental office:

First Name

Last Name

Phone

Address

City

Zip Code

Dentist/ Dental Office

Phone

Address

City

Zip Code

Reason for Disclosure:

If other:

I take full responsibility that the private dental records are going to be sent over the internet without security and the ability to verify that receiving party successfully obtained the files. Furthermore, there is an understanding that the file format may not be compatible. We issue all the x-rays in PDF format.

I understand that the x-rays are part of the original dental records that belong to Glossy Dental. We require 72 hours from the time of signature to process your request.

Please note that this form must be filled fully including your signature, Date, and Drivers License number that matches your original number when originally given to the practice.

Patient/Legal Guardian Signature

Driver License/ ID #

Date

If signed on behalf of patient:

First Name

Last Name

Relationship to Patient