www.lakewoodlaserdentist.com - Record Release Form

Record Release Form
Date*

MonthDayYear
Date
Please release a copy of my perio chart & any x-rays* from the last 3 years to:

Dr. Scott Stewart
stewartsmiles@hotmail.com
PATIENT’S SIGNATURE*

Clear
PATIENT’S NAME*

First NameLast Name
DATE OF BIRTH*

MonthDayYear
Dr. Patient is Requesting Records from:
DOCTOR’S NAME*

First NameLast Name
DOCTOR’S PHONE #*
Please enter a valid phone number.
*PLEASE SEND ALL X-RAYS, PARTICULARLY PANO OR FMX WITHIN 48 HOURS OF RECEIVING THIS REQUEST. Thank you!
Should be Empty:

Record Release Form