Records Release Request – Dental Center Pediatrics

I hereby authorize release of dental records for my child. Please complete all fields below and allow at least 2 (two) weeks for processing.

Child's Name(s) *

Dental Records Requested *

Bitewing X-rays Other Intraoral X-rays Panoramic X-rays Chart

Email to Send Records To *

Reason for Request *

Patient's Signature (type full name) *

Date *

Records will be emailed to the patient address provided above. Processing takes up to 2 weeks.

Thank you. Your records release request has been received.
Please allow up to 2 weeks for processing.