Xrays Release Form

Request Date:

General Dental Release

Please provide me with copies of all my dental records, x-rays, medication sheets, interpretations of tests, and progress notes pertaining to my treatment. I understand that my actual dental record, by law, belongs to my dentist. I understand that the information contained in the record belongs to me. I agree to accept copies of such records and to pay any fee(s) for duplication as required.

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 Name:

Guardian or Patient Signature:

Date:

Date of Birth:

SSN:

RELEASE SEND X-RAYS TO:

DR. NAME:

ADDRESS:

CITY:

STATE:

ZIP:

Office Use Only:

Date Received:

Date Copies Mailed:

Date Copies Emailed:

Staff Initial:

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