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RELEASE OF DENTAL RECORDS
I,(Name) 

Request to have dental records of those listed below transferred to:
Dentist: 
Appointment Date: 
E-mail address: 
Name of other family members to be transferred:
Name 
 DOB 
Name
DOB 
Name
DOB 
Name
DOB 
Name 
 DOB 
Name 
 DOB 

Signature: 

Signature Pad
Date: 

The PHI (Personal Health Information) contained in this form is highly confidential. It is intended for the exclusive use of the addressee.  It is to be used only to aid in providing specific healthcare services to this patient. Any other use is a violation of Federal Law (HIPAA) and will be reported as such.

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