Dental Records Release Form

"*" indicates required fields

Your First Name*

Your Last Name*

Patient Name*

Patient Date of Birth*

Your Relationship to Patient (Mother, Father, Legal Guardian, etc.)*

Your Phone Number

Your Email Address

Please choose the location of your most recent visit*

Please Release Patient Dental Records to:*

Name (first/last or name of Dental Practice)

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Fax Number

Reason For Records Request*

(i.e. moving out of the area, changing practices, etc.)

Records Needed By*

Please allow two business days for the records to be available.

Additional Notes/Special Requests

Unless otherwise requested, we will provide radiographs only.

Electronic Signature of Legal Guardian

Entering your name and date below serves as your electronic signature and confirms that the information submitted in this form is valid and accurate:

Name of Legal Guardian:*

First Last

*By signing this form, I verify that I am the legal representative for the patient listed above and authorize the release of dental records.

Date*

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