Request of Release of Records Form - McKinney
I hereby authorize the release of my dental records and/or copies of such. I understand it may take up to 24 hours for my records to be transferred. I request that they are transferred to:
Doctor or Hospital:
*
Doctor or Hospital Email Address:
example@example.com
Doctor or Hospital Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Doctor or Hospital Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Records:
-
Month
-
Day
Year
Date
Reason to Release records:
Referred for Treatment
Second Opinion
Seeking Treatment Elsewhere
If seeking treatment elsewhere, please specify a reason so we can improve. Thank you.
Patient Name
*
First Name
Last Name
Patient Date of Birth:
*
-
Month
-
Day
Year
Date
Todays Date:
*
-
Month
-
Day
Year
Date
I give McKinneyDentist.com permission to forward my records to the above recipient:
*
Agree
Disagree
Submit
Should be Empty: