Dental Records Release

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:
BlueSky Dental 2500 West A Street Suite 204 Moscow ID 83843 info@blueskydentistry.com 208-882-9111 (Phone) 208-882-3279 (Fax)

(Please email x-rays and history, including all placement dates for crown, bridges, etc if possible)
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
Address
Street Address City State / Province / Region ZIP / Postal Code