Request for Duplication of Dental Records

Request For Duplication of Dental Records

Patient Name *

Home Address *

Phone Number *

Authorization *

I am requesting copies of my dental treatment records and /or dental radiography. I understand that the original records and x-rays are property of dental practice.

Authorization *

I authorize you to send the information to (Please check one of the following options)

Information Section

Myself

Mail to *

Dentist *

Email Address *

Mailing Address *

* Please allow us at least 48 hours for processing your request. Thank you. *

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