Dental Records Release Form

MM slash DD slash YYYY
MM slash DD slash YYYY
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.

Name (first/last or name of Dental Practice)
MM slash DD slash YYYY
Please allow two business days for the records to be available.
Unless otherwise requested, we will provide radiographs only.
*By signing this form, I verify that I am the legal representative for the patient listed above and authorize the release of dental records.