Form

Request For Dental Records

First Name

Last Name

Date Of Birth

Spouse and/or Dependent Children Transfer:

Please forward any or all of my dental records including: x-rays, probing depth chart, charting and photographs to the below authorized individual, healthcare professional or facility.

I hearby consent that I have the legal right to grant you this permission and that the information I have provided is correct. I understand that if Kasey Davis Dentistry finds that I may not be authorized to request the transfer of this information that I may be asked to provide legal documents for power of attorney, custodial court documents or other authorization.

I understand that Kasey Davis Dentistry has the right to charge a reasonable, cost-based fee for the physical copies of my records and films; including any additional costs for postage or special mailing requirements (such as USPS Certified Mail or carrier expedited delivery services).

Please EMAIL my electronic records to (*NO FEE):

Please remit records to the following address:

*I understand there may be a fee for the physical (paper/film/non-digital) records.

Address

City

Zip Code

Phone Number:

If you are the patient, please type your name here then sign below.

Patient Signature

Date

If you are a representative of the patient(s), Your Name:

Relationship to Patient(s):

*Representative: Please upload proof of power of attorney, court-provided custodial proof or any applicable legal documentation in support of your request.

Drop files here to upload or Add Attachments Here

Legal Representative Signature

Contact Phone Number: