Free Dental Records Release Form

Please complete this form to authorize the release of your dental records to another dental provider or entity.
Patient Information
Patient Name
Date of Birth
Address
Phone number
Provider Information
Dental Practice Name
Address
Phone number
Release Information
I, the undersigned, authorize the release of my dental records:
To:
Address
Phone number
Purpose of Release
Personal Use
Transfer to Another Dentist
Legal Purposes
Patient Signature
Date:
Release Form Templates @ Template.net
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Streamline the process of sharing dental records with our customizable and editable Dental Records Release Form Template. Designed for efficiency, this template allows you to manage patient information securely and effortlessly. Utilize our AI Editor Tool to modify fields to suit your needs, ensuring a seamless experience for both dental professionals and patients.