Records Release

Records Release Form
**Please submit a separate form for each patient**
Patient Information
Name: *

First Name Last Name
Birthdate: *

Month Day Year
Date
Phone Number: *
Email *
example@example.com
Requesting Records From:
Name of Doctor or Clinic: *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Fax Number:
Email
example@example.com
By signing this form, I give Oak Grove Dental Center permission to obtain any and all medical and/or dental records needed for my treatment.
Signature of Patient or Parent/Guardian: *

Clear
Should be Empty:

Records Release Form