AUTHORIZATION TO RELEASE DENTAL RECORDS

Please complete this form to authorize the release of all copies of dental records and x-rays to the dental office of Sather Family Dental.

If you have questions about this form, call our office at 715.859.2202.

Patient Name *Your name (or the name of a minor if you are a parent or guardian requesting the dental records for a minor)

Patient's Date of Birth *

Your Email Address *Please include the email address for the person completing this form in case additional information is required

Phone NumberPlease include the phone number for the person completing this form in case additional information is required

Name of Your Previous Dentist *

Location of Your Previous Dentist *

Your Signature *

Start signing your signature here

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(Parent or legal guardian must sign if patient is a minor)

Today's Date *

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