Record Release
Disclosures to Family Member
Patient Name
*
First Name
Last Name
Patient DOB:
*
Exp:01/01/2000
I request the release of dental records relevant to:
Type of release:
*
Treatment record
Dental X-rays
Dental Charting
Billing
Dental Health Status
Health History
Other:
Release Records to:
*
First Name
Last Name
Date of Birth of person releasing to:
*
Exp: 01/01/2000
Patient or guardian Signature
Date
-
Month
-
Day
Year
Date
Patient or Guardians ID
*
Browse Files
Cancel
of
Guardian Name:
First Name
Last Name
Submit
Should be Empty: