Dental Records Release Form

Patient Information

First Name

Phone

Date of Birth

Last Name

Email Address

Last 4 digits of your Social Security

Street Address

City

Postal / Zip code

Region/State/Province

I hereby request that my dental records be released to:

Attention

Street Address

City

Postal / Zip code

Region/State/Province

Please let us know why you are changing dentist.

Please explain

By my signature I authorize the release of my dental records.

Please use your finger or curser to sign your name.

Your Signature

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Dental Records Release Form

Patient Information

I hereby request that my dental records be released to:

By my signature I authorize the release of my dental records.

Please use your finger or curser to sign your name.

Location

1451 Union Ave #130
Memphis, TN 38104
Phone (901) 272-1065

Office Hours

Monday: 8 a.m. - 5 p.m.
Tuesday: 8 a.m. - 5 p.m.
Wednesday: 8 a.m. - 5 p.m.
Thursday: 8 a.m. - 5 p.m.
Friday: Closed

Proud Sponsor
and Supporter

Dental Records Release Form

Patient Information

I hereby request that my dental records be released to:

By my signature I authorize the release of my dental records.

Please use your finger or curser to sign your name.

Location

1451 Union Ave #130 Memphis, TN 38104 Phone (901) 272-1065

Office Hours

Monday: 8 a.m. - 5 p.m. Tuesday: 8 a.m. - 5 p.m. Wednesday: 8 a.m. - 5 p.m. Thursday: 8 a.m. - 5 p.m. Friday: Closed

Proud Sponsor and Supporter

1451 Union Ave #130
Memphis, TN 38104
Phone (901) 272-1065

Monday: 8 a.m. - 5 p.m.
Tuesday: 8 a.m. - 5 p.m.
Wednesday: 8 a.m. - 5 p.m.
Thursday: 8 a.m. - 5 p.m.
Friday: Closed

Proud Sponsor
and Supporter