Records Release Form

To release dental records, please fill out the form below.

About You

Your Name(Required)

First Last

Date of Birth(Required)

Your Email Address(Required)

Home Phone(Required)

Mobile Phone

Your Address(Required)

Street Address Address Line 2 City State ZIP Code

Consent to send dental records

Where would you like your dental records sent to?

Name/Office

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email

Phone

Reason

Consent to receive dental records

Name of Dental Office Sending Records

Please call the office with any questions regarding this request: 480-899-6677

Patient Name

Date of Birth

Patient Name

Date of Birth

Patient Name

Date of Birth

Additional Information

Comments or Questions:

I understand that my express consent is required to release my dental records. I hereby consent to the release of my records according to the instructions on this form. My signature below confirms that I am authorized to make this request.

Signature of patient or patient’s authorized representative(Required)

Date(Required)

Relationship or status if signed by anyone other than patient listed above

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