Record Release Form to Us

Amazing Smile Family Dental Center

Please correct the errors described below.

To Whom It May Concern,

We are requesting the records fror the following patient(s) transferring to our office.

Add another patient name

Please forward any current records you may have at your earliest convenience to the above address or e-mail.

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

Your information will be encrypted.