Release of Records Consent

9907 Maple Grove Parkway
Maple Grove, MN 55369
Phone: 763-416-0011
FAX: 763-416-5006

Please print your name and the name of any family members whose x-rays you want copied:

I herby give Grove Health Dental permission to obtain my previous dental information.
Please send all most recent x-rays and history to Even if it is outdated! Thank you!