Forms & Records Authorization to Request Dental Records From Another Office Name * First Name Last Name Date of Birth * MM DD YYYY Phone * (###) ### #### Email * This form authorizes Inwood Family Dental to request and receive dental records from the provider listed below: * Name of Dental or Specialist Practice: Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Last Date of Treatment (Month/Year) * Information Requested: * Copy of Complete Dental Chart Copy of Dental X-Rays (email preferred) Copy of Periodontal Charting Other (models, scans, etc.) If other, please specify: AUTHORIZATION: * I request and authorize the above-named healthcare provider to release the information specified above to Inwood Family Dental – Dr. Selina Gutierrez. I certify that this request has been made voluntarily and that the information given above is accurate to the best of my knowledge. I understand that this authorization is good for one year, unless the dates are filled in below: From Date MM DD YYYY To: MM DD YYYY Method of Delivery (choose one): I understand that if I choose to receive records by email or fax, there is a risk the email or fax could be intercepted or read by an unauthorized third party. Mail paper copies to my address above (fee will be charged for printing and postage) Email electronic copies Pick up in person Fax I may revoke this Authorization at any time in writing, except to the extent that action has already been taken to comply with it. * Patient First and Last Name: Signature of Patient/Legal Representative: * Relation to Individual: Date Signed * MM DD YYYY Thank you! Patient Information:
