www.centreplacedental.com - Release of Records Form

Release of Records Form
I (patient or guardian) hereby request and authorize (dentist or dental practice) to provide copies of any current films and necessary records or notes concerning my care to
CENTRE PLACE DENTAL.
Click (+) for add more
All records can be emailed to Centre Place Dental at secure@centreplacedental.com. Thanks!
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty: