Copper Dental Records Release

REQUEST OF MEDICAL INFORMATION

REQUEST FOR X-RAYS
To*
First and Last Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient*
First and Last Name
Date of Birth*

MonthDayYear
Date
Please send duplicates of recent films for the patient above to the address below, or email to: admin@copper-dental.com.

Copper Dental

Dr. Melinda Judd, DMD

1945 NW 2nd Street

McMinnville, OR 97128
I authorize the release of my dental x-rays to Dr. Melinda J. Judd D.M.D.
Signature of Patient or Guardian*

Clear
Date*

MonthDayYear
Date
Should be Empty: