Skip to content
843-818-5437
Make a payment
Request an appointment
Search
About Us
About Coastal Kids Dental & Braces
Reviews
Careers
Dentists
Dental Services
Dental Cleanings
Dental Crowns
Dental Fillings
Dental Sealants
Dental X-Rays
Fluoride Treatments
Laser Tongue and Lip Tie Correction
Oral Health Exams
Orthodontics
Pulp Therapy for Kids
Sedation Dentistry
Space Maintainers
Special Needs Dentistry
Tooth Extractions
Parents
Your First Visit
New Patient Form
Insurance
Request Records
Emergencies
Blog
Request Appointment
Locations
Carnes
Dorchester Rd.
Hanahan
Moncks Corner
Mt Pleasant
Rivers Ave
Summerville
Walterboro
West Ashley
Contact Us
Make a Payment
Specials
About Us
About Coastal Kids Dental & Braces
Reviews
Careers
Dentists
Dental Services
Dental Cleanings
Dental Crowns
Dental Fillings
Dental Sealants
Dental X-Rays
Fluoride Treatments
Laser Tongue and Lip Tie Correction
Oral Health Exams
Orthodontics
Pulp Therapy for Kids
Sedation Dentistry
Space Maintainers
Special Needs Dentistry
Tooth Extractions
Parents
Your First Visit
New Patient Form
Insurance
Request Records
Emergencies
Blog
Request Appointment
Locations
Carnes
Dorchester Rd.
Hanahan
Moncks Corner
Mt Pleasant
Rivers Ave
Summerville
Walterboro
West Ashley
Contact Us
Make a Payment
Specials
843-818-5437
Dental Records Release Form
Date
MM slash DD slash YYYY
Your Phone Number
Your First Name
*
Your Last Name
*
Patient Name
*
Patient Date of Birth
*
MM slash DD slash YYYY
Your Relationship to Patient (Mother, Father, Legal Guardian, etc.)
*
Photo Identification
Max. file size: 1 GB.
All release forms must have a copy of the parent/guardians’ photo ID attached or records will not be released. Please ensure that picture of identification documents are clear and easy to read.
Please choose the Coastal Kids location of your most recent visit
*
Select office location
Carnes
Dorchester Rd.
Hanahan
Moncks Corner
Mount Pleasant
Rivers Ave
Summerville
Walterboro
West Ashley
Please Release Patient Dental Records to:
*
Name (first/last or name of Dental Practice)
Email
*
Address
*
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Phone Number
*
Fax Number
Reason For Records Request
*
(i.e. moving out of the area, changing practices, etc.)
Records Needed By
*
MM slash DD slash YYYY
Please allow two business days for the records to be available.
Additional Notes/Special Requests
Unless otherwise requested, we will provide radiographs only.
Signature
*By signing this form, I verify that I am the legal representative for the patient listed above and authorize the release of dental records.
Δ