RELEASE OF RECORDS

RELEASE OF RECORDS

Enter your information below
I Full Name authorize my previous dentist, Dr. First Name Last Name Dentist’s address Street Address City State Zip Phone: Phone Number Fax: Faxto release any and all dental records to:
TRU Dental, PC
3849 Foothills Rd, Suite A, Las Cruces, NM 88011
Email: office@TRUdentalnm.com

This authority to release includes, but is not limited to: dental reports, clinical notes, doctor’s notes, subjective and objective complaints, radiographs, any pertinent medical information, interpretations of a diagnostic test (including a copy of the report), diagnosis and prognosis, progress notes, prescription history, and any other document records or information in your possession relative to my past, present and future dental condition.
Please forward records for the following patients:
Full Name:
Date of Birth:

MonthDayYear
Full Name:
Date of Birth:

MonthDayYear
Full Name:
Date of Birth:

MonthDayYear
Full Name:
Date of Birth:

MonthDayYear
This authorization to release the information on the above named patient(s) is subject to the following statement. State law prohibits you from making further disclosure of such information without specific written consent of the person(s) to whom the information pertains or is otherwise permitted by state law.
Patient’s Signature*

Clear
Date:*

MonthDayYear
Date
Patient’s Address: Street Address City State Zip Phone Number: Area Code Phone Number
Please verify that you are human*
Should be Empty: