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
Year
Month
Day
3
Please note there is a duplication fee of $10.00. Please allow us 3 business days
to duplicate your X-rays after your payment is received.

I hereby authorize the doctor and the staff AV Dental Associates PA to release
records or knowledge concerning my dental health to:
4
Full Doctor Name* This field is required.
5
Doctor Information* This field is required.
6
The information disclosed is:

Dental X-Rays

Dental Records
7
Date* This field is required.
Date
Month
Day
Year
8
Signature* This field is required.
Clear
Should be Empty: