Dental Clinic Release Form
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
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X-rays (e.g., panoramic, bitewing, periapical)
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Dental Treatment History (e.g., fillings, root canals, extractions)
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Periodontal Records (e.g., gum disease treatments, deep cleanings)
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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!
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