Medical Records Release Form Prepared and delivered within two (2) business days Please Fill Out Our Form To Request Your Records Patient Name Patient DOB Choose an Office Hatboro Philadelphia My permission is granted to Best Dentist 4 Kids to disclose to the following, complete information concerning the medical findings and treatment of the Patient named above. Email to Send Records to: Recipient Office / Contact Name Additional Information Parent / Guardian Signature Confirmation By signing my name above, my permission is granted to Best Dentist 4 Kids to disclose to the Office/Contact above, complete information concerning the medical findings and treatment of the Patient. Send
