DENTAL RECORD RELEASE FORM

Gabriel Orverholtzer, DDS.

325 Grove Street Bishop, CA 93514

Dental Record Release Form

Patient Name

Date of Birth

Phone Number

Email

Members of Family

Previous Dentist of Practice Name

Address

Phone Number

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.

Dated

Do you Agree