PERMISSION TO RELEASE RECORDS
Dental Office Name:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email:
example@example.com
Phone Number:
Please enter a valid phone number.
Please check a box:
Have all current x-rays emailed to Apelgren Dental at info@apelgrendental.com
Have Apelgren Dental email all current x-rays to another office
Patient Name:
DOB:
-
Month
-
Day
Year
Date
Patient/Guardian Signature:
Today's Date:
-
Month
-
Day
Year
Date
Submit
Should be Empty: