Patient Release Of Dental Records Form

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Patient Release of Dental Records Form
(Please Print or Type)
I, _______________________________, do hereby request and give my permission to
(Patient and/or Guardian’s name)
release my dental records from the following Dental Office:
Office Name:____________________________________
Address:_________________________________________
City:__________________________ State:________ Zip:____________
Phone Number:____________________________________
The Dental Records as listed on the bottom of the page are to be released to:
Name: __L. Tim Choy, DMD___________________________
Address: 1733 Woodside Road, Suite 100___________
City:_Redwood City____State _CA_ Zip 94061____
Phone Number: ____(650)716-4888_____________________
Fax Number: ____(650)716-4966_______________________
Email (preferred method): ______info@drtimchoy.com____________
_____________________________
___________
Printed Patient/Guardian Name
Date of Birth
_____________________________
____________________________
Patient or Guardian Signature
Today's Date
Copies of the following are specifically requested:
 Progress Notes
 Letters/Reports to/From Specialists
 Periodontal Charting
 Radiographs
 Medical history forms
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