DENTAL RECORD RELEASE FORM

    Gabriel Orverholtzer, DDS.

    325 Grove Street Bishop, CA 93514

    Phone (760) 873-6513, Fax (760) 873-8555

    Dental Record Release Form

     

    Please forward my dental records (X-rays, perio charting and notes) to Skyline Family Dentistry.

    Digital Images can be emailed to skylinereceptionist16@gmail.com

     

    I hereby give you permission to release any and all of my dental records.

     

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    Tuesday: 8am – 5pm
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    Thursday: 8 am – 5pm
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    Sunday: Closed

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