Records Release

Records Release Form
**Please submit separate form for each patient**
Patient Information
Name:

First NameLast Name
Birthdate:

MonthDayYear
Date
Phone Number:

Area CodePhone Number
Phone Number:
Format: (000) 000-0000.
Email:
example@example.com
Requesting Records From:
Name of Doctor or Clinic:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Phone Number:

Area CodePhone Number
Fax Number:
Format: (000) 000-0000.
Fax Number:

Area CodePhone Number
Email:
example@example.com
By signing this form, I give Oak Grove Dental Center permission to obtain any and all medical and/or dental records needed for my treatment.
Signature of Patient or Parent/Guardian:
Oak Grove Dental Center

2250 SE Oak Grove Blvd Ste A

Oak Grove, OR 97267

Phone: 503-654-9521

Fax: 503-654-1695

Email Records to: frontdesk@ogdental.com
Should be Empty:

Records Release Form