Records And Radiographs Release Form

Date

Patient's Name

Previous Dental Office Name

Address

Phone Number of Previous Office

This form is to request release of records and radiographs for the above patient to our office.

Please email them to drattisano@leonardattisanodmd.com

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.

Patient's Signature

Date

Please accept this electronic signature in lieu of a physical signature.

Your information will be encrypted.