Free Dental Clinic Release Form

Please fill out this form to authorize the release of your dental records to a specified third party.
Name
Date of Birth
Address
Phone number
Recipient Information
Name of Recipient (Individual or Organization)
Address
Phone number
Specific Records to Release
X-rays (e.g., panoramic, bitewing, periapical)
Dental Treatment History (e.g., fillings, root canals, extractions)
Periodontal Records (e.g., gum disease treatments, deep cleanings)
Orthodontic Records (e.g., braces, retainers, aligner treatments)
Date Range of Records
Reason for Record Transfer
Authorization and Acknowledgement
I authorize the release of my dental records to the specified recipient and acknowledge understanding of my privacy rights.
Name:
Date:
Thank you for your submission!
We appreciate you taking the time to submit.
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Simplify the process of releasing dental records with Template.net's Dental Clinic Release Form Template. This editable and customizable form ensures a smooth transfer of patient information to third parties. Tailor it to your clinic’s needs using our AI Editor Tool, designed for ease of use and efficiency. Perfect for streamlined record management!