Dental Records Release Form

Date
Date Format: MM slash DD slash YYYY
Your Phone Number
Your First Name*
Your Last Name*
Patient Name*
Patient Date of Birth*
Date Format: MM slash DD slash YYYY
Your Relationship to Patient (Mother, Father, Legal Guardian, etc.)*
Photo Identification
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.
Please choose the Wild Smiles location of your most recent visit*
Please Release Patient Dental Records to:*
Name (first/last or name of Dental Practice)
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Phone Number*
Fax Number
Reason For Records Request*
(i.e. moving out of the area, changing practices, etc.)
Records Needed By*
Date Format: MM slash DD slash YYYY

Please allow two business days for the records to be available.
Additional Notes/Special Requests
Unless otherwise requested, we will provide radiographs only.
Signature
*By signing this form, I verify that I am the legal representative for the patient listed above and authorize the release of dental records.