Dental Records Release Form

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DENTAL RECORDS RELEASE FORM
Patient Name to transfer: ________________________________________________________________
Date of birth: __________________
Phone number: __________________
Other family members to transfer: _________________________________________________________
Please forward any of the following information that you have: recent x-rays, probing depth chart and
photographs to:
Dentist or Practice Name: _________________________________________________________
Address: ____________________________________________________
City, State, Zip: _______________________________________________
Phone Number: _________________________
Email Address: _________________________
I hereby give permission to release any and all of my dental records to:
________________________________________________________ (Dentist or Practice Name)
______________________________
_________________________
Patient Signature (parent, if a minor)
Date
DISCLOSURE:
This message is intended only for the use of the individual(s) to whom it is addressed and contains information that is privileged,
confidential, and exempt from disclosure under applicable law. Any further dissemination of copying of this communication is strictly
prohibited. If you have received this communication in error, please notify us immediately by telephone or email. This message is
provided in accordance with HIPAA Omnibus Rule of 2013.

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