Release of Dental Records and X-rays

Release of Dental Records and X-rays

Please note we send our x-rays via email in most cases, and ask for 24 business hours. On 3d cone images they can only be mailed due to the size of the image.
Patient Name*

First NameLast Name
Patient Date of Birth*
Exp: 01/01/2000
I hereby authorize Dr. Ramin Homanfar and staff to release records or knowledge concerning my dental health to:
Full Doctor's Name:*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Doctors Email
example@example.com
I specifically request that you release copies of:
Current X-rays
Other:
Charting notes
Signature

Clear
Date

MonthDayYear
Date
Patient or Guardian ID*

Browse Files

Cancelof
Guardian Name:

First NameLast Name
Should be Empty: