Dental Records Release Form

Please correct the errors described below.



Radiant Dental of Bedford 902 Echo Vale Drive Bedford, PA 15522

To Pick up my records (Photo ID required)


Only information from the past five (5) years will be disclosed. Unless dates filled in below.

When transferring information to another dental office we only send current x-rays (bitewing x-rays, full mouth x-rays & panorex) within the last 5 yrs and treatment dates for prophy’s (cleanings) – exams – scale & root planning.

If you want us to release other information then please mark below.

EXPIRATION: This Authorization is good for one year unless dates filled in below

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.

If signed by a person other than the patient, complete the following:

By signing, I understand that the information released per this authorization, if redisclosed by the recipient, is no longer protected by Radiant Dental of Bedford.

Your information will be encrypted.