Records Release – Smilecenterspa

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

MEETYOUR DENTAL TEAM

Our Location

Appointment

Quick Links

Locations

Contact Info