Dental Record Release Form
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Authorization
Full name of the dentist that is to be authorized
First Name
Last Name
Delivery Options
Delivery
E-Mail
Fax
Address for dental records to be sent
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-Mail for dental records to be sent
example@example.com
FAX# for dental records to be sent
Information to be disclosed
Treatment Plan
Radiology films
Billing records
Specific information that is to be disclosed
Specific information that is NOT to be disclosed
Expiration date
From
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
To
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of the patient / legal representative
Submit
Should be Empty: