Free Dental Records Release Form Template
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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