Request for Release of Records
Today's Date:
*
-
Month
-
Day
Year
Date
Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Previous Dentist:
*
Dentist's Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dentist's Phone Number
-
Area Code
Phone Number
Previous Dentist's Email:
example@example.com
I authorize the release of my records including radiographs to be sent to Chatham Dental, PLLC. Please email to: chathamdental@yahoo.com If unable to e-mail please send to: 1 Houseman Ave Chatham, NY 12037
Signature
*
Submit
Should be Empty: