Dental Records Release Form

Dental Records Release Form
PATIENT INFORMATION
I hereby authorize Terence QL Young, D.D.S., Inc. to release information for the dental records of the following patient(s):
Patient Name*

FirstLast
Date of Birth

MonthDayYear
Date
FirstLast
MonthDayYear
Date
FirstLast
MonthDayYear
Date
Patient Name

FirstLast
Date of Birth

MonthDayYear
Date
FirstLast
MonthDayYear
Date
FirstLast
MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
I am requesting information for:

Services provided from a specific dateAll service dates
From

MonthDayYear
Date
To

MonthDayYear
Date
Information to be released (please select all applicable):

history of services renderedmost recent radiographsFMX or panoramic radiograph
Purpose of release:

movingtransferring care to a new dentistOther
Please release information to:

New DentistPatient or Parent/ Legal Guardian
Name

First NameLast Name
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Email
example@example.com
Phone Number
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
Method of delivery:

e-mail (*recommended*)in-office pick-up
AUTHORIZATION
I acknowledge that the above requested records will NOT be released until any existing balance has been cleared from my family’s account.

I understand that this entire form must be completed before any records can be released.

I acknowledge that this authorization is valid for a period of 6 months or until expressly revoked by me. I understand that I may withdraw this authorization by submitting a written, dated request, and that such revocation does not affect action that has already been taken based on this authorization.
Signature*

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Date*

MonthDayYear
Date
Relationship
Should be Empty:

Dental Records Release Form

PATIENT INFORMATION

AUTHORIZATION