Records Request
Patient's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Records being requested: Current dental radiographs, if any, and patient history.
Please send requested records to:
E-mails sent to personal email addresses will be unencrypted. We do not recommend sending patient information in an unencrypted email because third parties may be able to access the email.
I certify that I have the legal authority under federal and state laws to make this request on behalf of the patient identified above.
Name of Patient's Personal Representative
*
First Name
Last Name
Relationship to Patient
*
Signature of Personal Representative
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: