Dental Records Release Form

  1. Your Full Name
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  2. Email
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  3. Number of Children for which you are seeking records release.
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  4. I, hereby, release all dental records including radiographs and daily treatment notes.
    I also release you from all legal responsibility or liability that may arise from this authorization.

  5. 1. Child's Full Name
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  6. 2. Child's Full Name
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  7. 3. Child's Full Name
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  8. 4. Child's Full Name
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  9. 5. Child's Full Name
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  10. 6. Child's Full Name
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  11. Address
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  12. City
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  13. State
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  14. Zip Code
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  15. Where do you want us to send the records?
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  16. Recipient/Office Name
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  17. Address
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  18. City
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  19. State
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  20. Zip Code
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  21. I certify that the information provided in this form is correct to the best of my knowledge.
    I also certify that I am the person who I claim to be and I am not falsely representing another individual.

    Use your mouse or trackpad to sign on a computer. Use your finger or stylus pen to sign on a touchscreen device.

  22. You must agree to these terms to submit this form.
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  24. • Upon receipt of this signed release form, any and all scheduled appointments will be cancelled.
    • Dental Records will be released to Legal Guardian. Initial copy of records is at no charge. A fee will be assessed for additional copies.
    • Records will be transferred once all dental claims have been received and all balances are paid in full.
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