Form

Release of Records Consent

9907 Maple Grove Parkway
Maple Grove, MN 55369
Phone: 763-416-0011
FAX: 763-416-5006
info@grovehealthdental.com

Please print your name and the name of any family members whose x-rays you want copied:

Name:

Date of Birth

Name

Date of Birth:

Name

Date of Birth

New Office Name:

New Office Phone Number:

New Office Email Address:

I herby give Grove Health Dental permission to forward my previous dental information to the above practice.

Patient/Legal Guardian Signature

Date