Dental Records Release Form
Patient Name: ________________________ Date of Birth: _____________________
Previous Dentist or Practice Name: _______________________________________________________
City/St/Zip : __________________________________________________________________________
Phone number: __________________________ Fax number: ____________________________
Please forward any of the following patient information that you have included, but not limited
to: x-rays, probing depth chart, charting, and photographs to Family Dental Wellness.
I hereby give you permission to release any and all of my dental records to:
FAMILY DENTAL WELLNESS
2108 WEST STATE STREET
OLEAN, NY 14760
If records are digital please send to
May also be faxed to (716) 379-8488.
We appreciate your prompt attention to this request. Thank You!
Check here if you are requesting additional family member’s under 18 records and list
Family Dental Wellness
(716) 373-1210 Phone
(716) 379-8488 Fax