Request for Release of Records
Today's Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please reference REQUESTING TO Chatham Dental or FROM Chatham Dental
*
I authorize the release of my records including radiographs to be sent TO Chatham Dental, PLLC. Please email to: chathamdental@yahoo.com If unable to e-mail please send to: 1 Houseman Ave Chatham, NY 12037
I authorize the release of my records including radiographs to be sent FROM Chatham Dental, PLLC. to the above named practice/dental office.
Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Last 4 of SS:
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dental office:
*
Dental office address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dental office Phone Number:
-
Area Code
Phone Number
OFFICE Email: *NEEDED TO SEND DIGITAL XRAYS
example@example.com
Signature
*
Submit
Should be Empty: