Record Release Form

To Our Office

Please correct the errors described below.

request the release of dental records relevant to dental treatment, or copies of such, and request that they be transferred to:

Island City Smiles

1946 Wilton Drive, Wilton Manors, FL 33305

Email X-Rays to : info@islandcitysmiles.com

Name of Patient

Date of Birth

Name of Patient

Date of Birth

Name of Patient

Date of Birth

Records being Requested

Current Radiographs

Dental Health Status

Reports

Diagnostic Casts

Treatment Records

Charts

Health History

Prescription Records

Photos

Other

Other Explanation

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.

Patient Signature

Date

Signature of Parent/Guardian

Date

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Electronic signature

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