Dental Records Release Form

Dental Records Release Form
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to the Patient
Name if not the Patient

First NameLast Name
I hereby authorize you to release my/my family's (if applicable) dental records, including radiographs, charting and progress notes to the office of Jensen Dental.
Family members and dates of birth
Previous Dentist's Name
Previous Dentist's Office Number
Please enter a valid phone number.Format: (000) 000-0000.
We prefer digital records. Please securely email records to jensendentalmt@gmail.com.

Hard copies can be mailed to our office at:

1547 South Higgins Suite D

Missoula, MT 59801
Signature
Should be Empty: