Bluegrass Pediatric Dentistry Release of Records

Release of Records
Guardian Information
Parent/Guardian Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Patient Information
Patient Name
Date of Birth

MonthDayYear
Date
Recipient Information
Recipient Type

Parent/GuardianDental ProviderOther
Recipient Name/Office:
Fax Number
Please enter a valid phone number.
Email
example@example.com
Purpose of Release:

ReferralInsuranceOther
Records to Be Released:

All RecordsX-raysTreatment NotesOther
How Records Will Be Sent:

Printed for PickupFaxEmail
Signature of Parent/Guardian:

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Date

MonthDayYear
Date
Should be Empty: