Dental Records Request
GR8 SMILES OFFICE - LEVELLAND
Dear Patient our office is currently closed for renovations due to storm damage. Please fill out this contact form to request dental records or to be referred to another dental office. We apologize for any inconvenience this may cause.
I am trying to contact the office because:
I need my dental records.
I need a referral to another dental office.
I need copies of my X-rays.
I need to complete my treatment.
I have questions about my bill or payment.
Other
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Relation to the patient
*
I am the patient
Parent or Legal guardian
Other
Delivery Method
Email
Pick up in person
Fax
IMPORTANT
Please allow 3-5 business days for processing any of the options selected.
Email Address to send the Dental Records?
*
example@example.com
Fax or Phone Number
If you select the option FAX
Address to send the Information ( if need a physical Copy)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dental Records Authorization
*
Submit
Should be Empty: