Record Release Request Patient InformationFull Name *Date of Birth *Phone Number *Recipient Information (previous dental office)Recipient's Name (Dentist/Facility) *Phone Number *Records to be Released *Full Dental RecordAuthorization: I hereby authorize the release of my dental records . I understand that this authorization is voluntary and that I may revoke it at any time in writing.Signature *Sign hereYour browser does not support e-Signature field.Date *Submit
