Dental Records Release

Dental Records Release
Previous Dental Office Name
Previous Dental Office Phone
Format: (000) 000-0000.
Patient Information
Patient First Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Family Members
Patient Name 1

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Name 2

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Name 3

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Name 4

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I request you to release all my complete dental records listed above and release you of any legal obligations in proving this information to the following.
- Panorex within the last 5 years
- Bitewings within the last 2 years
- Periapical radiographs within the last 2 years
I hereby authorize the release of my family's dental radiographs from my previous dental clinic so that they can be transferred to DeerValley Dental.
First & Last Name

First NameLast Name
Email Address
example@example.com
Signature
Should be Empty: