Patient Form

Records Release Request

Use this form to authorize the release or transfer of dental records.

Please do not include emergency medical information in this form. If you are experiencing a life-threatening emergency, call 911.

Select office *

ZIP code

Patient

First name *

Last name *

Date of birth

Phone

Release details

Release records FROM (office/provider)

Release records TO (office/provider)

Records requested

Other / details

Authorization

I authorize the release of the dental records indicated above. *

Electronic signature

By typing my name below, I understand and agree that this electronic signature has the same effect as my handwritten signature.

Typed full legal name *

Date

I confirm this is my electronic signature and the information I provided is accurate.

By submitting this form, I understand that Valley Dental Care will use this information to contact me and prepare for my dental visit. See our Privacy Policy and Terms of Use.