Release Of Records

Please provide me with copies of all of my dental treatment records, including diagnostic x-rays and any other materials, notes or copies of medications prescribed. I understand that original records and x-rays are your property. I agree to accept copies and to pay reasonable fees for such copies.

I READ AND UNDERSTAND THE ABOVE INFORMATION AND THE INFORMATION GIVEN ME VERBALLY. BY MY SIGNATURE BELOW I CONSENT TO THE REATMENT DESCRIBED IN THIS PAPER.

Patient Information:

First Name:

Last Name:

Middle Name:

DOB:

Phone:

Email:

Patient Signature

Use your mouse cursor or the tip of your finger to sign below

Date:

Witness:

Date: