Authorization for Release of Dental Records & x-Rays

1
Patient Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
We do not charge a duplication fee as a courtesy to our patients, although it is permissible under NJ law. please allow us 24 hours for xray duplications and 3 business days for full record duplications.

I here by authorize the doctor and the staff of AV Dental Associates PA to release records or knowledge concerning my dental health to:
4
Full Doctor Name* This field is required.
5
The information disclosed is:

Dental X-Rays

Dental Records
6
Date* This field is required.
Date
Month
Day
Year
7
Signature* This field is required.
Clear
Should be Empty: