Dental Record Release Form

Authorizes a dental practice to send a patient's clinical history to a new dentist or another designated party.

Use this template

Patient Name

Nombre

Apellido

Date of Birth

Full name of the dentist that is to be authorized

Nombre

Apellido

Delivery Options

Mail Email Fax Pickup

Address for dental records to be sent

Dirección

Ciudad

Estado / Provincia

Código postal

E-Mail for dental records to be sent

FAX# for dental records to be sent

Information to be disclosed

X-rays Treatment history Billing records Other

Specific information that is to be disclosed

Specific information that is NOT to be disclosed

From

To

Signature of the patient / legal representative

Sign here

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