Dental Records Release Form

"*" indicates required fields

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.