Dental Records Release Request

Please Complete The Form Below

Child(ren) Whose Records Are To Be Released

Child's Name	Date of Birth	Actions

There are no Children.

Where do you want us to send the records?
- Home Address
- Doctor's Office
Doctors Office
Recipient/Office Name
Address
City
State
Zip Code
Signature Section
I certify that the information provided in this form is correct to the best of my knowledge.
I also certify that I am the person who I claim to be and I am not falsely representing another individual.
I Agree*
- I Agree
Signature
Use your mouse or trackpad to sign on a computer. Use your finger or stylus pen to sign on a touchscreen device.

Dental Records Release