Release of Records Request
Date
Patient Information
Full Name:
Date Of Birth
Mobile Phone:
Requested Records
Please identify the type of records that you would like us to release:
Form Delivery
Form Delivery
If Mail - Address records will be sent to
Address
City
State
Zip Code
Name of Physician to receive medical records:
Doctor’s or Practice Name:
Phone Number:
Email address:
Reason for request:
If going to another dentist, please share your reason why.
Authorization
If request is completed by a person other than the patient, complete the following:
Full Name:
Your Role:
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