Dental Records Release Form

Dental Records Release Authorization
Date

MonthDayYear
Date
Patient Name

First NameLast Name
Date of Birth:

MonthDayYear
Previous Dental Office

Please provide us with your PRIOR dental office name, phone number, and email address.
To:   Prior Dental Office/Provider Name*
City/State:   City/State*
Phone:   Area Code*   Phone Number*
By signing this form, I authorize the release of dental records relevant to dental treatment, or copies of such, and request that they be transferred to:

Salt Run Family Dentistry

Mickey Leth, DMD

Bert Tavary, DDS

Nicole Dunn, DDS

700 Anastasia Blvd. St. Augustine, FL 32080

904-824-3540

office@saltrundental.com
Patient Signature:
Should be Empty:

Previous Dental Office