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
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Patient Information
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Family Members

I hereby authorize the dental practice listed above to release my dental records, as well as the records of any individuals named above, to the requesting provider.

	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
2 digit month, 2 digit day, 4 digit year
Patient or Parent/Guardian Signature
{nameOf43}: Please ensure that all the requested information is provided to {practiceName} upon submission.
{contactEmail}
Should be Empty:

{practiceName}