www.mylifetimesmiles.com - Release of Dental Records Form

Release of Dental Records Form
I am requesting copies of my dental radiographs / records:
Patient's Name *

First NameLast Name
Patient's Date of Birth

MonthDayYear
Previous Dental Office*
Previous Doctor's Name*
Previous Dental Office Phone Number*
Please enter a valid phone number.
Select one

I would like copies of my records to be sent to the following email addressI would like copies of my records to be sent to the following physical address
Email address *
example@example.com
Physical address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Signature*

Clear
Patient Name*

First NameLast Name
Date*

MonthDayYear
Should be Empty: