Request for Release of Records

Request for Release of Records
Date:*

MonthDayYear
Date
I (Patient Name)*
hereby request and give my permission to Little Urban Smiles to provide
Dr.*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
any and all information which he/she may request with respect to the dental care of
Patient *
Such records may include medical care and treatment, illness or injury, dental history, orthodontic history, medical history, consultation, prescriptions, x-rays, models and copies of all dental records and medical records.

I agree to pay the cost of duplicating any records. (N/A) A photocopy of this release will be as effective and valid as the original.
Patient Signature*

Clear
Date*

MonthDayYear
Date
Social Security # N/A
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Signature (Parent, Legal Guardian or Custodian of the Patient if appropriate*

Clear
Date*

MonthDayYear
Date
(Parent, Legal Guardian or Custodian of the Patient, if appropriate)
Print Name*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Should be Empty: