Dental Records Release Form

Your First Name*
Your Last Name*
Patient Name*
Patient Date of Birth*
MM slash DD slash YYYY
Your Relationship to Patient (Mother, Father, Legal Guardian, etc.)*
Your Phone Number
Your Email Address
Please choose the 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*
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.
Electronic Signature of Legal Guardian

Entering your name and date below serves as your electronic signature and confirms that the information submitted in this form is valid and accurate:
Name of Legal Guardian:*
First Last
*By signing this form, I verify that I am the legal representative for the patient listed above and authorize the release of dental records.
Date*
MM slash DD slash YYYY
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