Medical Records Release Form

Prepared and delivered within two (2) business days.

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Please Fill Out Our Form To Request Your Records

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 below.

Patient Name *

Patient DOB *

Choose an Office *

Email to Send Records to *

Recipient Office / Contact Name *

Additional Information

Parent / Guardian Signature *

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.

Medical Records Release Form

Please Fill Out Our Form To Request Your Records

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