Dental Records Release Form

Dental Records Release Form
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Add Additional Patient? *

Yes No
Patient Name

First Name Last Name
Date of Birth

Month Day Year
Date
Add Additional Patient?

Yes No
Patient Name

First Name Last Name
Date of Birth

Month Day Year
Date
Add Additional Patient?

Yes No
Patient Name

First Name Last Name
Date of Birth

Month Day Year
Date
Add Additional Patient?

Yes No
Patient Name

First Name Last Name
Date of Birth

Month Day Year
Date
Date of Request *

Month Day Year
Date
Reason for Release *

Transfer of Records 2nd Opinion Other
Reason for Transfer *
Transferring Information
Dentist/Practice Name *
Phone for Dentist/Practice *
Number for Dentist/Practice
Address for Dentist/Practice *
Email for Dentist/Practice *
example@example.com
Type of records to be released *

Dental records & x-rays X-rays only Orthodontic records & x-rays
By signing below, I am authorizing Natick Dental Partners to release any records of the individuals listed above including any radiographs that my family or I may have at this office.
Signature (patient over 18, parent or legal guardian) *

Clear
Print Name *
Should be Empty:

Transferring Information