Records Release Form Records Release Form Patient First Name(Required) Patient Last Name(Required) Patient Birth Date(Required) MM slash DD slash YYYY Records are to be released: To me in person In person to my authorized representative (please list name below) By mail to my home address (please list address below) By mail to my Dentist (please list address below) By email - Radiograph Only (please list email address below) Records release info from above: Parent/Guardian Name(Required) Date(Required) MM slash DD slash YYYY Message(Required) Δ
