Dental Records Release Form


MM slash DD slash YYYY
MM slash DD slash YYYY
Max. file size: 1 GB.
All release forms must have a copy of the parent/guardians’ photo ID attached or records will not be released. Please ensure that picture of identification documents are clear and easy to read.

Name (first/last or name of Dental Practice)
Address*
(i.e. moving out of the area, changing practices, etc.)
MM slash DD slash YYYY
Please allow two business days for the records to be available.
Unless otherwise requested, we will provide radiographs only.

Electronic Signature of Legal Guardian

Entering your name and date below serves as your electronic signature and confirms that the information submitted in this form is valid and accurate:


Name of Legal Guardian:*
MM slash DD slash YYYY