Dental Record Release Form

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

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Patient Name

First Name

Last Name

Date of Birth

Full name of the dentist that is to be authorized

First Name

Last Name

Delivery Options

Mail Email Fax Pickup

Address for dental records to be sent

Street Address

City

State / Province

ZIP / Postal Code

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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