Back
Release of Information
Patient First Name
Patient Last Name
Email
Patient Date Of Birth
Phone
Release of Information
Records may be released to:
Wilson and Pfau Family Dentistry
288 Northwood Avenue
Jasper, IN 47546
Phone: 812-482-1855
Email: smiles@wilsonandpfau.com
*emailed records are preferred. Please call if you are unable to send via email
Reason for Disclosure:
If Other:
Request records from:
Phone
Address
City
State
Zip Code
Email
Consent
Sign Here
×
Signature Pad
Date
Back
Next
Back
Next
Submit
Done