Record Release Form

Date

Doctor/Clinic

Address

City

State

Zip

Email address

Fax #

Patient Name

Date of Birth

I hereby authorize the release of my dental records and x-rays or copies of such and request that they be transferred TO or from (Circle one) Mark Family Dental.

Date of Record Request

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

Your information will be encrypted.