Dental Records Release Form - Des Moines Pediatric Dental Center

Date

Your Phone Number

Your First Name*

Your Last Name*

Patient Name*

Patient Date of Birth*

Your Relationship to Patient (Mother, Father, Legal Guardian, etc.)*

Photo Identification

Max. file size: 1 MB.

All release forms must have a copy of the parent/guardians’ photo ID attached or records will not be released. Please ensure that picture of identification documents are clear and easy to read.

Please Release Patient Dental Records to:*

Name (first/last or name of Dental Practice)

Email*

Phone Number*

Fax Number

Reason For Records Request*

(i.e. moving out of the area, changing practices, etc.)

Records Needed By*

Please allow two business days for the records to be available.

Additional Notes/Special Requests

Unless otherwise requested, we will provide radiographs only.

Signature

*By signing this form, I verify that I am the legal representative for the patient listed above and authorize the release of dental records.