Dental Records Release Form printable pdf download

Dental Records Release Form

Patient Name to transfer:

__________________________________________________________________

Date of Birth: _____________________ Phone number: ______ _____________

Other family members to transfer:

__________________________________________________________________

Previous Dentist or Practice Name:

__________________________________________________________________

Address:

__________________________________________________________________

City/State/Zip :

__________________________________________________________________

Phone number: ______ _____________

Please forward any of the following information that you have:

X-rays, treatment records, treatment plans, and photographs to Kelli Junker DDS, Inc.

I hereby give permission to release any and all of my dental records to Dr. Junker.

_____________________________________ __________________

Patient Signature (parent if a minor)

Date

If records are digital, please email to:

Or mail to:

Kelli Junker DDS

400 Newport Center Dr, #708

Newport Beach, CA 92660

(949)640-2970 tel

(949)640-2838 fax

Dental Records Release Form