www.drchildreth.com - RECORDS RELEASE REQUEST

RECORDS RELEASE REQUEST
I authorize the release of dental records, dental X-rays and medical records relevant to dental treatment, or copies, to be transferred to the office of Jeff E. Childreth D.M.D.
Patient’s Signature
Print Patient’s Name

First NameLast Name
Date

MonthDayYear
Date
Jeff Childreth DMD
3546 Lone Pine Road, Medford, OR. 97504
541-772-8846, fax 541-732-1878
frontoffice@drchildreth.com
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