Health Centered Dentistry-Records Release

Records Release Patient Details

First Name*

Last Name*

Middle Name

Date Of Birth*

Address*

City*

State*

Zip*

Gender

Marital Status

Social Security Number

Driving License Number

Email*

Cell Phone Number*

Home Phone Number

Work Phone Number

Records Release Additional Patient Names

Please print names of any dependents under age 18 (if applicable):

Records Release Release Records FROM Other Office

Name of Office or Doctor:

City

State

Office Phone

Office Fax

Electronic records are preferred. Please email the records to: hcdrecords@hcdentistry.com.

Records Release HCD Release Records TO

Name of Office or Doctor:

City

State

Office Phone

Office Fax

Office Email

Reason for Records Release:

Please allow 48 hours for records to be ready for delivery.
All records will be delivered electronically unless otherwise requested.

Records Release Consent for Release

SIGNATURE ()*

(Please click below to draw/upload sign)

(Your IP Address :IP:184.72.102.217 )

Date

Preview