Androscoggin Dental Care- Patient Records Release Form

Patient Records Release Form

Androscoggin Dental Care
Date*

MonthDayYear
Date
Patient Name*

First NameLast Name
Patient Date of Birth:*

MonthDayYear
Date
Email
example@example.com
I would like my dental records sent to:*

Androscoggin Dental CareAnother Dental Office
Please fill in the blanks below

Previous Dental Office:Name of Practice Here* may Release Records to:

Name of Practice: Androscoggin Dental Care
Mailing Address: 7 Main St., Topsham ME. 04086

Email Address: adc@beautifulsmile.com
Phone: (207) 729-3911
Fax: Fax: (207) 204-3427
Please fill in the blanks below

Androscoggin Dental Care may Release Records to:

Name of New Dental Office:Name of Practice Here*
Mailing Address:
Email Address:ex: info@newdentaloffice.com*
Phone:207-555-1212
Fax:207-555-1212
The records that will be included, but are not limited to: personal patient information, medical and dental histories, examination records, and radiographs, clinical photographs, treatment plans, treatment records, referral and consultation recommendations and reports, diagnostic models, and other related materials.

I expressly release from liability the above names person or entity from any and all liability arising from compliance with this request and disclosure of the requested information.
Are you the patient or a parent/guardian?*

PatientParent or Guardian
Please Type Your Name*

First NameLast Name
Patient Signature: (use mouse or finger to draw your signature)*

Clear
Please type the name of the Patient's Parent or Guardian signing the release*

First NameLast Name
Parent / Guardian Signature: (use mouse or finger to draw your signature)*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty: