CA Request for Release of Records

{practiceName}

Email: {contactEmail}

Request for Release of Records from Previous Dentist
Account ID*
Env*
Practice Name*
Practice Recipient Email*
Previous Dentist Information
Dentist Name

First NameLast Name
Dental Practice Name*
Phone Number*

Area CodePhone Number
Email Address
example@example.com
Patient Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Phone Number*

Area CodePhone Number
Additional Family Members

END
I authorize the previous dental practice listed above to release the following dental records for myself, and those named above:*

YesNo

	Last Appt Date (to be filled out by previous Dentist)
· Treatment History (Complete Oral Exam)	_____________________
· Treatment History (Recall Exam)	_____________________
· Treatment History (Hygiene/Scaling)	_____________________
· X-Rays (Bitewing)	_____________________
· X-Rays (Full Mouth)	_____________________
· X-Rays (Panorex/Panoramic)	_____________________
· Any additional medical history, dental history, test results, photographs and/or radiographs (upon request by the dental practice)	_____________________

Date

MonthDayYear
Patient or Parent/Guardian Signature*

Clear
{nameOf43}: Please ensure that all the requested information is provided to {practiceName} upon submission.
{contactEmail}
Should be Empty:

{practiceName}