465 S. Drake Rd., Kalamazoo, MI 49009
(269) 344-7222 info@drakedental.net
Records Release
Date
-
Month
-
Day
Year
Date
Patient Name(s)
To Drake Dental - please forward to address or email listed above
From Drake Dental - please forward to address or email listed below
Email or Address:
Reason for request:
Moved from the area
Change in insurance
Other
Name
First Name
Last Name
Signature - Please draw your signature using your finger if on a mobile device or mouse cursor if on a computer. Your full signature must be included for your form to be valid.
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Which of our offices should receive your form?
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Kalamazoo
Portage
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