OperaDDS - Form

Authorization for the Release of Records

Office Name

Office Phone Number:

Office Fax or Email:

Patient Name:

Patient's Date of Birth:

Pure Care Dental is requesting the following dental records:

Full Mouth Radiograph or Pano within the last five years
Bitewing radiographs within the last twelve months
If applicable; dates of service for scaling and root planing done at your office and periodontal charting.

Patient or Legal Guardian Signature

Date