Dental Records Release Form

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Max. file size: 1 MB.
    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)
  • (i.e. moving out of the area, changing practices, etc.)
  • 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.