Records Release

RECORDS RELEASE REQUEST FORM

Name (First, Last)

Email (We will email records to this email address)

Phone number (Required)

Message (Optional)

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.

Select Location

ABINGTON OFFICE WILLOW GROVE OFFICE MONTGOMERY MALL

RECORDS RELEASE REQUEST FORM

Our Location

Appointment

Quick Links

Locations

Supply

Contact Info