Release of Records Date - must be mm/dd/yyyy format * Required Date Format: MM slash DD slash YYYY Dental Provider / Clinic Name * RequiredDental Provider/Clinic Name Address * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Dental Provider/Clinic Phone * RequiredDental Provider/Clinic Email Consent * Required I authorize the release of dental records and x-rays relevant to dental treatment.I authorize the release of dental records and x-rays relevant to dental treatment, and request that they be transferred to: Dental Health Services Email: dhsm[email protected] Fax: (320) 634-3567Patient First Name * Required First Patient Last Name * Required Last Patient Email * Required Patient Birthdate - must be mm/dd/yyyy format * Required Date Format: MM slash DD slash YYYY
