Release of Records Form

"*" indicates required fields

Date

I, (name of patient, parent or guardian)*

Hereby request and authorize (name of previous dentist/dental clinic)*

To provide Barton Dental with copies of my/my family's dental records, radiographs and any other information as outlined below.

Phone number of previous dentist/dental clinic:*

Email of previous dentist/dental clinic:*

Family Member 1

Family Member 2

Family Member 3

Signature of patient, parent or guardian:

Date