Form

Release of Records

Patient's First Name

Patient's Last Name

Date Of Birth

Release of Information:

I authorize the release of my information including x-rays, photos, chart records, and financial information. I acknowledge that electronic communication is not a secure or encrypted method for transmitting medical information and accept all associated risks, including potential unauthorized access or disclosure. Despite these risks, I voluntarily consent to and wish to proceed with the electronic delivery of my medical information via email, if checked below.

Fees:

Fees for obtaining dental records are established by the Texas State Board of Dental Examiners. Once your request is received, an invoice will be issued for the total amount due. Please allow up to 30 days for processing from the date payment is received before records are released.

Records may be released to:

First Name

Last Name

Phone

Address

City

Zip Code

Format:

Purpose: (select all that apply)

If Other:

Consent

Date

Driver's license or other government-issued ID (*required):

Upload or drag files here

For Office Use Only:

I have reviewed the patient's chart for completeness and accuracy and authorize the release of records.

Name of Treating Dentist:

Signature

Date