Dental Records Release Form

Dental Records Release Form

Provide your details and authorize us to request your dental records from your previous dentist.
Synergy Dental Solutions · Dr. Angie Tenholder, DMD, FAACP, DABCDSM, FAGD · 1000 Eleven South, Suite 3F, Columbia, IL 62236 · Phone (618) 281-9729 · Fax (618) 281-9734 · WeCare@WeAreSynergy.com
Patient and previous dentist
Patient name to transfer

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Are there other family members to transfer?
Other family members to transfer
Previous dentist or practice name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Fax number
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Authorization and signature
Please forward any of the following information that you have: x-rays, probing depth chart, charting and photographs to Synergy Dental Solutions.
I hereby give you permission to release any and all of my dental records to Synergy Dental Solutions.
Who is signing?
Patient signature
Signature of personal representative
Authority of personal representative to sign for patient (check one)
Other (please describe)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If records are digital, please email to: WeCare@WeAreSynergy.com. Or mail to: Synergy Dental Solutions, 1000 Eleven South, Suite 3F, Columbia, IL 62236
Should be Empty:

Dental Records Release Form

Patient and previous dentist

Authorization and signature