Request for Release of Records

Request for Release of Records
Date*

MonthDayYear
Date
Dental Office (Name/Location) we are requesting records from: *
I authorize the release of my dental records and/or x-rays, with dates taken to:

Morning Glory Dental

1745 N 86th Street

Lincoln, NE 68505

PH# 402-489-8848

www.morningglorydental.com

Please email x-rays to: morningglory1745@gmail.com
PATIENT NAME*

First NameLast Name
PATIENT DOB:*

MonthDayYear
Signature*

Clear
Should be Empty: