Release of Records
Guardian Information
Parent/Guardian Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Patient Information
Patient Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Recipient Information
Recipient Type
*
Parent/Guardian
Dental Provider
Other
Recipient Name/Office:
*
Fax Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Purpose of Release:
*
Referral
Insurance
Dental School Form
Other
Records to Be Released:
*
All Records
X-rays
Treatment Notes
Other
How Records Will Be Sent:
*
Printed for Pickup
Fax
Email
Signature of Parent/Guardian:
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: