Dental Records Release Form
By completing this form, I hereby request and authorize Garfinkle Family Dental to obtain copies of any and all clinical treatment records and information concerning my care from the below business. These records may include, but are not limited to examination records, radiographs, clinical photographs, treatment plans, treatment records, referral and consultation recommendations and reports. Email where the records are to be sent: garfinkledds@gmail.com.
Patient Information
Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Office Where the Records Are Located
Name of the Office/Business
Office/Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office/Business Phone Number
-
Area Code
Phone Number
Office/Business Email
*
By signing below, you authorize Garfinkle Family Dental to request your records on your behalf. Please allow up to two business days for your request to be processed and handled. If you have any additional questions or concerns, please don't hesitate to contact us.
Signature
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