Dental Records Release Form - Family Dental Wellness printable pdf download

Dental Records Release Form - Family Dental Wellness

Dental Records Release Form

Patient Name: ________________________ Date of Birth: _____________________

Previous Dentist or Practice Name: _______________________________________________________

Address: ____________________________________________________________________________

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!

Patient Signature

Date

Check here if you are requesting additional family member’s under 18 records and list

names below

Family Dental Wellness

(716) 373-1210 Phone

(716) 379-8488 Fax

Dental Records Release Form - Family Dental Wellness