Release of Records

Date - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY
Dental Provider / Clinic Name * Required
Dental Provider/Clinic Name Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Dental Provider/Clinic Phone * Required
Dental 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: [email protected]
Fax: (320) 634-3567
Patient First Name * Required
First
Patient Last Name * Required
Last
Patient Email * Required
Patient Birthdate - must be mm/dd/yyyy format * Required
MM slash DD slash YYYY

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