Form

Current Patient Request of Records

Patients: Please complete this form and we will send your records according to your request.
All patients age 18 and older need to complete and sign their own form.

Patient name

Date Of Birth

Patient name

Date Of Birth

Patient name

Date Of Birth

Patient name

Date Of Birth

Patient name

Date Of Birth

Please send records to the following:

Office Address

Office Email

Office Phone Number

By signing this form I authorize Orono Dental Care to send all relevant dental records for the people listed above to the person/office I listed above.

Patient/Legal Guardian Signature

Date