Record Release Form

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

Date of Request

My permission is granted to:

to disclose to Dr. Kurt Peterson the complete information concerning the medical findings and treatment of patient:

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 insurance@petersondental.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.

Name:

Address:

Thank You

1604 W. Riverside Avenue • Spokane, WA 99201
www.petersondental.com • kurt@petersondental.com
(509) 747-2183 ph
(509) 747-3990 fax

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