Record Release Form

Please correct the errors described below.

Kurt E. Peterson, DDS
1604 W. Riverside Ave
Spokane, WA 99201
ph (509) 747-2183
fax (509) 747-3990

Please include current bitewings, any FMX or PANO taken within the last 5 years, probe readings and dates of 4341, if any. All records can be faxed to the number above or emailed to

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.

Thank You

1604 W. Riverside Avenue • Spokane, WA 99201 •
(509) 747-2183 ph
(509) 747-3990 fax

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