Dental X-Ray Records Release Form

Dental X-Ray Records Release Form
Authorize the release of your dental X-ray records to a designated recipient. Please complete all required fields to process your request.
Patient Full Name
First NameLast Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Email Address
example@example.com
Patient Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Recipient Name (Person or Facility to Receive Records)
First NameLast Name
Recipient Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Recipient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reason for Release of X-Ray Records
Description of Dental X-Ray Records to be Released
Preferred Method to Receive Records
Other
Signature of Patient or Legal Guardian
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