Dental Records Release Form Template
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Dental Records Release Form

Please complete this form to authorize the release of your dental records to another dental provider or entity.

Patient Information

Patient Name

    Date of Birth

      Address

        Phone number

          Provider Information

          Dental Practice Name

          Address

            Phone number

              Release Information

              I, the undersigned, authorize the release of my dental records:

              To:

              Address

                Phone number

                  Purpose of Release

                    • Personal Use

                    • Transfer to Another Dentist

                    • Legal Purposes

                    Patient Signature

                    Date:

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