Name (First, Last)
Email (We will email records to this email address)
Message (Optional)
Phone number (Required)
I am requesting my dental records/ X-rays to be released to me for personal use. By signing this form I affirm the pickup of the records/Xrays. I also acknowledge that I have received the Notice of Privacy Act of Practices of this office.By providing last 4 digits of my social I authorize the office to email me my records.
Last 4 digits of your social
