Record Release Form

Contact US

Email: misslousmiles@bellsouth.net
Telephone: 318-336-9688
Fax: 318-336-9804

I [Enter Name Below], authorized

Dr. [Enter the doctor's name below], to release a copy of all of my dental records including radiographs to Dr. S. Lee Falkenheiner, DDS.

Social Security #:

Date of Birth:

Disclaimer: 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.

Signature:

Date:

Email: misslousmiles@bellsouth.net Telephone: 318-336-9688 Fax: 318-336-9804

Your information will be encrypted.