Dental Records for Another Office

I
hereby request and authorize
to disclose and provide copies of any and all clinical records including but not limited to x-rays, perio charting and chart notes to the following:
I expressly release from liability the above named person or entity from any and all liability arising from compliance with this request and disclosure of the requested information.
Patient signature
Patient name
Relationship to patient
Date
MM slash DD slash YYYY
Phone number
Patient address